minor“for two people who had recently started using the service, no risk assessments had yet been carried out.”
moderate“Important information such as the name of the prescribed medicine, the strength of the medicine, the prescribed dose and allergy status were missing from the record.”
staff training
2 findings
moderate“training for essential topics such as Mental Capacity Act (MCA) and first aid was out of date.”
moderate“Records of training were maintained, and these showed that several staff were not up to date with medicines management training.”
communication with families
2 findings
moderate“some people had reported communication barriers. One relative told us, 'Training needs to be given to staff and they need to be fluent in English.'”
minor“three people who thought visit times could be improved and office communication”
medication management
2 findings
critical“Out of the 19 records reviewed, we identified gaps in the medicine administration records (MARs) for five people for multiple medicines.”
critical“Several staff had not completed training in the safe administration of medicines in the past 12 months, nor had their competence to administer medicines assessed.”
governance
2 findings
critical“Systems for monitoring and improving the quality and safety of care were not effective...issues had not been effectively addressed.”
moderate“They did not have a robust system for auditing records of financial transactions carried out by staff on behalf of people using the service.”
other
1 finding
minor“staff application forms asked prospective staff to declare their 'Ethnic heritage'. We discussed this with the nominated individual who agreed that the question should not be asked.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post. A manager had been appointed and the provider told us it was their intention that the manager would apply to register with CQC before the end of March 2023.”
staff competency
1 finding
minor“five people and their relatives told us that their enquiries were sometimes misunderstood at times by staff working at the office.”
missed or late visits
1 finding
critical“21 people had short calls more than 10% of the time in November 2020...Ten people had calls late by more than 45 minutes more than 10% of the time in September.”
complaints handling
1 finding
minor“The five unresolved complaints were still in the process of being remedied and involved visit times, staff being asked to complete tasks outside of the package.”