5 March 2019
During an inspection looking at part of the service
People’s experience of using this service:
¿ Poor practice and ineffective governance systems had resulted in people missing visits and receiving late care calls, which had not been followed up. One person said, “They come at different times and don’t stay the full time. A lot of the time they don’t turn up. I’m constantly having to chase it up and never get a call back.”
¿ The service had ineffective systems in place to protect people from harm. The assessment of risk and medicines management across the organisation was inadequate. Advice and best practice guidance that we had shared with the provider at the previous inspection had been ignored.
¿ People were put at risk as the management team lacked clear oversight and knowledge of what was happening across the service. People continued to receive support from staff who had been suspended pending safeguarding investigations.
¿ The quality of care people received had deteriorated since the previous inspection.
¿ The culture of the service lacked openness, honesty and transparency. The management team were dishonest and provided inaccurate information, which placed people at harm as serious incidents were not acted upon.
¿ People and their relatives highlighted how the lack of communication impacted upon the service they received. One person said, “I call them and they never respond. It is now over a week since they were supposed to call and they haven’t.”
We found three continuing breaches of regulations in relation to safe care and treatment, good governance and notifiable incidents. We found two new breaches of regulations in relation to safeguarding people from abuse and improper treatment and failure to display their ratings. You can see what action we told the provider to take at the end of the full version of this report.
Rating at last inspection: At the last inspection the service was rated Requires Improvement. (Report published 9 October 2018).
Why we inspected: This was an unannounced focused inspection due to information of risk and concern we had received. At the previous inspection, we found breaches of three regulations and served two warning notices.
Enforcement: We have kept this service under review while we took action to cancel the providers registration as a result of breaches in regulations resulting in people receiving inadequate care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk