critical“Systems and processes had not identified the lack of regular review to risk assessments and support plans. These had not been updated following any incidents or accidents.”
critical“lack of a robust, evidenced quality assurance system and the lack of recorded oversight by the provider was a breach of regulation 17”
moderate“provider's monitoring and quality assurance processes had not identified the issues we found relating to procedures around medicines management”
moderate“last inspection we highlighted the lack of depth of the care plan audit. The audit had not improved, and the third-party auditor's report also highlighted the lack of a care plan audit”
critical“Systems and processes to monitor and improve the quality and safety of the service were not adequate. This was a breach of Regulation 17(1)”
critical“care plan audits... had not been done recently and the registered manager could not recall the last time it had been done... at least eighteen months”
record keeping
6 findings
minor“It wasn't clear if a morning call to someone needing personal care had been undertaken due to the method of logging in.”
minor“field managers completed spot checks, but these had not been logged in the quality assurance system”
minor“written outcomes to complaints were not always provided or recorded within the complaints file”
minor“did not clearly record post-incident observations for people in 24-hour care following potential head injuries”
moderate“none of the audit sections had been completed for either person's records we reviewed...audit tool was a simple check for the presence or absence of standard documents”
moderate“There was no date on it, so it was difficult to know when the next review was due... most recent one dated from October 2014 (20 months earlier)”
care planning
5 findings
moderate“Risk assessments had not been reviewed and revised following any incidents or accidents. We found no evidence of harm caused to people, but the lack of review increased the risk of reoccurrence.”
critical“risk assessments were of variable detail, with some containing very little information about how to support the person to manage and reduce the identified risk”
minor“staff had not given full consideration as to how they could meet recommendations made in relation to one person's health care needs”
moderate“one person's care plans had not been updated following a significant change in their care needs...information was not always clearly or consistently presented”
moderate“some files did not contain a great deal of personal information. When they did, some details were wrong. For example one person was recorded... as Church of England, but in fact... Roman Catholic”
incident learning
3 findings
moderate“the same issues. Risk assessments and staff guidance were brief and did not provide sufficient information for staff to manage the known risks”
moderate“medicines audit had not identified this shortfall...audit has also failed to recognise the gaps on this person's MARs as a potential issue”
critical“We had not received any notifications of any kind since November 2014... notifiable events were not being reported. This was a breach of Regulation 18”
medication management
3 findings
moderate“Premier Care systems were not being used to manage any changes in people's medicines and to record the action taken where issues were found with the MARs”
moderate“two occasions in February 2019 when there had been a delay in one person receiving their medicines (some of which it was important they received in a timely way)”
critical“recording of one medicine not contained in the blister packs was inconsistent...we were not able to tell whether this medicine had been given correctly”
person centred care
3 findings
minor“keyworker system had lapsed as staff had been re-allocated around the service and needed to be re-instated so people had more involvement in their support”
moderate“limited evidence of people, or others involved in their care were included in the development and review of their care plans...implemented inconsistently”
minor“no practical work had been done with them to start the process... the service could play its part in moving away from a maintenance model”
safeguarding
2 findings
critical“the local authority had not been informed about concerns that calls had been claimed as being completed when they hadn't been”
critical“some of the incidents recorded in these logs had not been identified as safeguarding incidents and reported to the relevant authorities”
staff training
2 findings
moderate“up to 18 topics were covered over a three-day period during the induction...Seven of the 28 staff were overdue their refresher training by between one and four months”
critical“Nearly a third of staff were overdue refresher training. A course in recognising signs of mental distress had been discontinued... for two years”
complaints handling
2 findings
minor“The policy stated that all complaints should be acknowledged in writing within two days. We found this was not being done.”
minor“The complaints policy was out of date... dated 2010 and required updating”
leadership
1 finding
moderate“There was no registered manager in post at the time of this inspection. The provider was committed to ensuring the right person was appointed to the position of registered manager.”
supervision appraisal
1 finding
moderate“KPI record sheet showed a large number of staff spot checks, competency observations and supervisions had not been completed as scheduled”