critical“MARs were not consistently completed with numerous gaps where we could not establish whether people had received their medicines as prescribed.”
moderate“Medicines profiles did not always reflect people's current prescribed medicines.”
critical“MARs we reviewed were poorly completed and it was not clear what medicines had been prescribed or when they had to be administered.”
moderate“We found a number of gaps on medicine administration records (MARs) where we could not confirm if people had received their medicines as prescribed.”
moderate“Some handwritten MARs were not signed by staff to confirm the prescription was correct.”
governance
4 findings
critical“Systems and processes to assess, monitor and improve the quality and safety of the service were not sufficiently robust.”
moderate“we raised concerns with the registered manager about DBS checks not being re-checked during employment.”
critical“lack of strong leadership, ineffective quality assurance systems, weak communication and poor record keeping meant issues we found at this inspection had not been identified or resolved.”
moderate“The management team recognised audits of the medicine management system needed to be more robust.”
record keeping
3 findings
moderate“MARs and daily records were not consistently brought back to the office on a regular basis. This meant timely checks and audits of these documents were not always completed.”
moderate“some records were without evaluation dates and records of staff signing to show their understanding of the care records.”
moderate“registered manager told us they met with staff every Friday...but there were no minutes of their discussions.”
care planning
3 findings
minor“Care plans were subject to regular review to ensure they remained up-to-date. People and/or their relatives told us they had been involved with this process, although this was not formally documented.”
moderate“People's care records did not always fully reflect their needs... there was no evidence of this support being delivered.”
moderate“one person who had diabetes and had a recent hospital admission due to low sugar levels did not have an appropriate risk management plan in place to help reduce the risk.”
incident learning
3 findings
minor“conclusions and outcomes were not routinely documented and the registered manager agreed this was an area for further improvement.”
critical“person had fallen while staff had been present, the person had sustained a head injury and been admitted to hospital. There was no accident report for this incident.”
minor“Accidents and incidents were recorded with action taken. However, further analysis was required to analyse themes and trends to mitigate the risk of reoccurrence.”
staff training
2 findings
moderate“Some staff had not received any practical training in how to operate moving and handling equipment such as stand-aids, hoists and slide sheets.”
critical“one care worker with no previous experience in care had not completed basic areas of training, such as food hygiene, safeguarding, infection control and first aid awareness, until after they had worked for the service for three months.”
consent capacity
2 findings
critical“The service were not able to evidence documentation that showed indicated people had legal powers to act and consent on people's behalf.”
moderate“registered manager confirmed they had received training in the Mental Capacity Act 2005...they told us none of the staff had completed Mental Capacity Act Training.”
missed or late visits
2 findings
critical“finish time at one call was the same as the start time at another, however, the calls were 3.8 miles apart and the AA route planner calculated this journey would take 13 minutes.”
minor“staff apologised if they were late, but did not always phone to inform them.”
end of life care
1 finding
minor“We found a lack of information recorded in people's care records as to their end of life care needs and preferences.”
staff competency
1 finding
moderate“At the time of the inspection, staff competency assessments had not been undertaken, although we saw a plan was in place to address this.”
safeguarding
1 finding
critical“one staff member who had worked in the service for two years told us they had received no safeguarding training and were unable to describe the different types of abuse.”
supervision appraisal
1 finding
moderate“In one care worker's file we saw their last annual appraisal had been completed in September 2013.”
complaints handling
1 finding
moderate“complaints raised were not always dealt with appropriately or resolved. This was a breach of the Regulation 16 of the Health and Social Care Act 2008.”
staffing levels
1 finding
moderate“Insufficient care staff were being deployed to ensure people's needs were met in a timely way.”
person centred care
1 finding
minor“lack of information about people's lives, preferences or interests in the care records we reviewed. Only one of the people we spoke with said they had been involved in reviews of their care plan.”
communication with families
1 finding
critical“next of kin had not been informed by the agency of the fall or that the person had been admitted to hospital.”