moderate“Where people were prescribed 'as and when required' medicines to be taken up to 4 times a day, there was not always a 4-hour gap in between staff administering them.”
moderate“some paper records lacked details of the specific dose that had been administered. This meant there was not a clear record of how much medicine the person had received”
moderate“some staff lacked access to the electronic administration records (e-MARs) and therefore unable to monitor previous electronic administration records”
staffing levels
2 findings
critical“one staff member visited 9 people over the course of their shift, where no travel time was allocated. The average travel time accumulated was 58 minutes.”
moderate
“five out of the seven staff spoken with felt this travel time was not always sufficient... I do feel I have to rush the care calls at times which really upsets me.”
care planning
2 findings
moderate“People's care plans did not always contain enough information for staff to understand how to mitigate risks... other identified risks lacked sufficient detail.”
moderate“one person had a catheter in place and another person was diagnosed with diabetes. There were no risk assessments in place for these conditions”
governance
2 findings
critical“Audits being completed had not identified the concerns we found during our inspection... no overall auditing process to identify if staff arrived on time.”
moderate“some systems in place to assess, monitor and improve the quality of the service had not been effective. Both the registered manager and senior management team had failed to identify”
missed or late visits
2 findings
moderate“They are supposed to be here for an hour, but I never get an hour... They can be up to an hour and a half late sometimes.”
minor“There was one incident when the carer forgot about me. I rang the office and they made sure they came around.”
communication with families
2 findings
moderate“I have called [the office] several times, but nothing gets done... If I ring [the office] and complain it doesn't go anywhere.”
minor“The outcome of these surveys were not reflected on in the Monthly Auditing Report' for October 2021 and there was no evidence available which demonstrated people's views or concerns had been acted on”
safeguarding
1 finding
critical“we found 4 occasions where CQC had not been notified of safeguarding concerns, 3 of which had also not been shared with the local authority safeguarding team.”
incident learning
1 finding
moderate“they had failed to identify where some incidents or concerns raised, were safeguarding and further action was required to ensure people were safe.”
leadership
1 finding
moderate“staff told us they felt undervalued and not listened to by the senior management team.”
record keeping
1 finding
moderate“lack of robust systems in place for monitoring and reviewing people's paper records. This meant there may be a delay in identifying concerns or issues”