critical“MARs did not always represent an accurate record of all prescribed medicines and topical creams administered...1 person's MAR had been used for training/demo purposes.”
moderate“Staff completed training to administer medicines but had not had their competence assessed before working unsupervised.”
moderate“No documented checks had been carried out to show medicines had been administered as prescribed.”
governance
3 findings
critical“Audits had not been fully effective in driving improvement...care plan audits contained repeated actions without evidence of resolution.”
critical
“The failure to have effective systems in place to assess, monitor and improve the quality and safety of the service was a breach of regulation 17 (Good Governance)”
critical“No formal audits of care provision, medicines, staff records, or care plans had been carried out.”
record keeping
3 findings
moderate“Some records were incomplete, outdated, or inaccurate...some information was inaccessible because the service was unable to access emails of a former staff member.”
moderate“No stock checks of medicines were carried out.”
moderate“There were no records of interviews despite the providers policy stating, 'The assessments made by interviewers must be formally recorded on an interview assessment form.'”
infection control
2 findings
critical“The service had not established or effectively implemented robust infection prevention and control procedures to effectively mitigate risk to people.”
minor“The staff don't tend to wear face masks. On arrival they do, but they take them off.”
staff training
2 findings
moderate“Staff had completed significant amounts of hours of training of many different subjects in 1 day...1 staff on 9 March 2023 had spent 15 and a half hours training.”
moderate“There were no documents in place to show that staff had received an induction into the service.”
staff competency
2 findings
moderate“The medication competency assessment workbook answers we reviewed were populated with internet responses. We were not assured this was an adequate process to assess staff competency.”
moderate“The provider's recruitment policy was not being followed.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post. The nominated individual had submitted an application to be appointed as the registered manager.”
moderate“Staff surveys had been carried out. However, these had not been analysed or used to improve the service.”
communication with families
2 findings
moderate“Professionals told us they did not always receive a timely response to emails, and a professional noted instances where the service had failed to arrive at planned joint visits.”
moderate“No formal feedback through reviews was sought from people using the service or their relatives. Informal telephone conversations took place, but these were not documented.”
supervision appraisal
2 findings
minor“The supervision matrix did not always match up with the supervision forms in staff files.”
moderate“Staff had not had formal supervision sessions. The nominated individual said they had spent one to one time with staff offering support, but this had not been documented.”
safeguarding
1 finding
critical“The service had failed to operate effective systems to identify, investigate and appropriately respond to allegations of abuse. This was a breach of Regulation 13(1).”
care planning
1 finding
critical“Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.”
incident learning
1 finding
moderate“Systems were not operated to analyse accidents/incidents, complaints and safeguarding concerns to identify trends or themes.”
staffing levels
1 finding
moderate“The rotas we reviewed did not give staff sufficient travel time. One staff had back-to-back visits where no travel time had been allocated, however visit locations were 30 minutes away.”
person centred care
1 finding
minor“A safeguarding document stated a person 'uses all kinds of tricks' to decline care...records described them as 'little bit tricky' and said they would 'finally play victims of poor care'.”
consent capacity
1 finding
minor“Although people had signed the initial assessment document, there was no formal consent to care recorded.”