moderate“we could not be assured that other medicines information in care records was always up to date or readily available when needed.”
moderate“for one person we could not see the record to support the decision to give medicine covertly.”
moderate“investigations into three recent medication errors and discrepancies with medicines stock were being conducted by the service.”
moderate“The MAR for one person had been changed by the staff but the changes were not made clear. Staff had crossed duplicate medicines in the MAR but had not detailed the reasons for this.”
moderate“There were people that were prescribed with medicines that required stricter recording controls. Some staff showed a lack of awareness of these guidelines.”
record keeping
4 findings
critical“records relating to people's care were not always comprehensive and up-to-date. This placed people at risk of harm.”
minor“Risk assessments, care plans and behaviour plans were in place...but further work was needed to ensure that these plans were regularly reviewed and kept up to date”
minor“two of the five staff files examined had failed to do this [provide full employment history]. During the inspection this was rectified”
moderate“In two services staff had not kept accurate records of medicines received.”
governance
3 findings
critical“systems were either not in place or robust enough to demonstrate the service was effectively managed. This placed people at risk of harm. This was a breach of regulation 17.”
moderate“auditing of care plans, these checks had not always been fully effective in identifying shortfalls in people's records to ensure they remained up to date”
moderate“References from the previous employer was not requested for one staff. The assessment of risk was not documented.”
care planning
3 findings
critical“People who have a diagnosis of epilepsy did not always have clear guidelines and protocols for staff to follow to support them safely.”
moderate“people's support plans and risk assessments had not always been reviewed to reflect people's current needs and levels of risk.”
minor“Two care plans referred the reader to the speech and language therapist recommendations and to their risk assessments without detailing the content in the care plans.”
staffing levels
2 findings
moderate“people had not always received correct staffing levels or expertise from staff who knew them well.”
moderate“Agency staff are used most shift. Inconsistencies of care delivery when agency staff were used. Recruitment is a problem.”
leadership
2 findings
moderate“Staff did not consistently know and understand the provider's vision and values. One staff member said, 'I don't know what [the Provider] wants and I don't know what they stand for.'”
moderate“The frequent management changes are disconcerting. A number of staff across the service had left since the change of ownership.”
infection control
2 findings
minor“Staff did not consistently wear PPE in line with the guidance and providers policy.”
minor“One of the three shared living locations that we visited was in need of better cleaning regimes. Housekeeping staff were not visiting and the support workers were having to undertake housekeeping regimes.”
incident learning
2 findings
moderate“We saw evidence that encouraged reflective practice following medicines incidents however, we did not see evidence to prevent future occurrences.”
critical“there had been three safety incidents between people that had not been reported appropriately. This placed people at risk as the provider could not check whether people had been supported safely”
supervision appraisal
2 findings
minor“debriefs with senior staff after accidents and incidents...had been offered, they not always been carried out so missing the opportunity to learn and evolve”
minor“Some staff said they had not had regular one to one supervision meetings.”
communication with families
1 finding
moderate“One relative said, 'I haven't seen the care plan and there's quite a few times that the phone hasn't worked for weeks and weeks.'”
person centred care
1 finding
minor“still needed to encourage people to get out and about, to be more independent and to have greater community access”
consent capacity
1 finding
moderate“Mental capacity assessments were not always in place for staff to administer medicines.”