critical“There were no medicine administration records [MAR] forms...it was not possible to confirm if people had been given their medicines.”
critical“one MAR recorded a person was to be given senna or movical. It did not detail the prescription for each medicine and staff had not recorded which of these medicines had been administered.”
critical“one staff member told us they had given a person their eyedrops but had not received any medication training.”
moderate“the director was unable to locate the assessment records... There was no reference to this in their assessment of need or care plan.”
moderate“there was a discrepancy when we looked at one person's medication administration record and daily notes... had not been picked up by the provider prior to the inspection.”
governance
4 findings
critical“There were no audits in place of care files or other systems of safety...the provider did not gather information about the quality of their service from a variety of sources.”
critical“Governance systems were not robust. There was no evidence of audits being carried out to monitor the service.”
minor“we recommend the service develops these further with a recognised quality accreditation scheme to help the service to learn and improve”
moderate“At the time of the inspection there were no medication audits.”
record keeping
4 findings
moderate“We looked in the staff member's file, there was no record of this disciplinary hearing...no record of the statement, the meeting or any record relating to this incident.”
moderate“Some assessments had not been signed by staff to show who completed the record. Some care plans lacked detail as sections had not been completed.”
minor“a health professional told us that daily recording could be improved, to enable them to be clear about what support had been delivered by care staff”
minor“one person was prescribed 'when required' medicine. There was no reference to this in their assessment of need or care plan.”
supervision appraisal
3 findings
critical“There were no annual appraisals in place. The registered manager agreed that supervisions had not been happening as they had been busy providing care.”
critical“one staff member had not had a supervision since 2016, another staff member had not had a spot check since 2017 and there had been no appraisal.”
minor“there was a variance in the level of support staff received... The provider had a supervision policy but this did not outline the frequency and method of staff support.”
staff training
2 findings
critical“There were no other records relating to ongoing training...no records held of when this training took place and who had received it.”
critical“one care plan directed staff to clean a catheter site. However, all the staff we spoke with said they had not received training in catheter care.”
care planning
2 findings
moderate“There was no record of care plans or risk assessments being reviewed on a regular basis.”
moderate“one care plan had not recorded a person's preferences for dressing. One person was being seen regularly by a district nurse, however, this was not identified in the care plan.”
consent capacity
2 findings
moderate“Staff we spoke with also displayed a lack of understanding of mental capacity...they had not received training in this area.”
moderate“Best interest decisions had not been recorded. However, staff knew those people who lacked capacity and what support they required.”
safeguarding
1 finding
critical“Both staff members could not provide answers about recognising abuse...staff were not clear on recognising and responding to possible abuse.”
complaints handling
1 finding
moderate“We saw complaints were not fully investigated and records in relation to staff conduct were not updated.”
staff competency
1 finding
critical“The service did not carry out the appropriate recruitment checks to ensure fit and proper persons were employed.”
incident learning
1 finding
moderate“we found medicine errors during our inspection which had not been investigated.”
end of life care
1 finding
moderate“People using the service were receiving end of life care. There was no end of life care plans in place to guide staff on how to support people.”