critical“the internal audit did not identify and manage the concerns we found to improve the service. There was an action plan attached to the audit, however the recommendations had not all been implemented.”
critical“The lack of a registered manager and changes in management affected the monitoring and follow up on staff training, effective supervision and learning from incidents”
critical“Provider's quality assurance and monitoring systems were not always effectively implemented...Audits had not identified these failures and therefore the manager had not taken action.”
critical“These audits had not identified the issues we found in some of these MARs.”
critical“There was no overall ownership, oversight or clear leadership at the service. The previous registered manager was no longer employed at the service.”
minor“The manager in post was new and had not yet registered with CQC as the registered manager.”
medication management
5 findings
critical“seven people's Medicines Administration Record Charts (MARs) had gaps in them. These gaps were either unexplained or had stated the medicine was not in stock so they could not administer them.”
critical“Medicines were not always managed in a safe way to meet people's individual needs...staff did not apply the cream...risk of the person's health condition deteriorating”
critical“One person's MAR had 14 medicines listed, but no staff signature for seven of them during four weeks in January 2020.”
critical“The MAR did not record the current dose of the medicine to be administered. This is critical information for staff because Warfarin doses are dependent upon the blood test results.”
critical“One person had run out of their medicines that helped to reduce the risks of choking due to a medical condition and this was not re-ordered.”
leadership
4 findings
moderate“Staff did not feel comfortable to raise their concerns because they felt insufficient action would be taken. 'There is a lack of management support and only when things go wrong the manager tells you off'”
moderate“There was a culture of distrust between staff and/or management. Staff told us they knew how to challenge practices but some were not confident that they would be listened to”
moderate“Senior managers were reactive to the concerns we found rather than having insight to the service and acting proactively.”
minor“The recent change in manager had created some uncertainty as they were not sure what a new manager brings.”
record keeping
4 findings
moderate“Pre-employment checks were not routinely collected before staff began to work at the service. We found inconsistencies in three staff records one application form was missing.”
minor“Checks were not sufficiently robust...audits had not picked up that staff had not ensured the person signed as stated in the policy and procedures”
critical“Medicine administration records (MARs) were not always completed accurately...the medicines audit did not find the concerns we found regarding the medicines that were not administered.”
moderate“The provider failed to ensure audits were completed accurately and failed to maintain accurate records for all people using the service.”
person centred care
4 findings
moderate“The provider had not ensured the service was fully meeting the AIS. People's care assessments recorded they had specialist communication needs... however, care records did not provide sufficient information.”
critical“A relative told us that care workers only completed tasks that were scheduled...soiled bedding that needed to be washed...refused by staff because the person was not scheduled to have their laundry completed.”
moderate“What I don't like is when they shout. They think I'm deaf and I want them to listen to what I've got to say instead of shouting me down.”
moderate“I want to go toilet they say it's not your time yet and I've asked how long have I got to wait.”
staffing levels
3 findings
critical“a person told us that they had become unintendedly incontinent because two members of staff were not available to support them to go to the toilet when they needed this level of support.”
critical“One night I had to wait for four hours as I am not allowed to get out of the chair. I'm not safe, I'll fall”
critical“The provider had not ensured there were sufficient staff to meet people's needs safely. These issues were a breach of Regulation 18”
incident learning
3 findings
moderate“the housing and care manager recorded all incidents that occurred at the service, however there was no detail of learning from those incidents that occurred or the actions taken to improve the service.”
moderate“Staff spoken to were not aware of some incidents that had happened at the service...we did not see any evidence of how the team benefitted from any learning from incidents”
moderate“Two people had consistently declined to take their medicines. This pattern of refusing medicines was not identified by staff and they had not supported the person to seek medical advice.”
care planning
3 findings
moderate“a person's risk assessment had not been updated when a change in transfer equipment was suggested following an occupational therapist's assessment.”
critical“The care plan did not reflect changes in the person's needs. The person's falls risk assessment did not indicate options available when staff did not have a hoist”
moderate“Staff did not always use people's information to provide them with appropriate care to meet their individual needs.”
staff competency
2 findings
critical“three newly employed members of staff had not fully completed their medicines training or medicine competency assessments since their employment began in November 2018, March and April 2019.”
moderate“The critical information regarding their competency to support people with their medicines unsupervised was not commented upon. Neither of the three competency assessments were signed or dated.”
staff training
1 finding
moderate“13 members of staff including the housing and care manager staff that had expired training in basic life support and safeguarding of vulnerable adults.”
cultural competency
1 finding
minor“People's cultural heritage and religious beliefs were recorded, but there was no evidence that the provider took any action to meet people's individual needs.”
communication with families
1 finding
minor“Contact details for people and relatives were incorrect despite requesting updated details.”
safeguarding
1 finding
critical“Three people gave staff money to complete shopping for them. On each occasion the till receipts did not match the information that was recorded on the provider's financial transaction form.”
missed or late visits
1 finding
moderate“Sometimes I don't have a carer, they don't turn up and they don't say they not coming.”
consent capacity
1 finding
moderate“People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.”