critical“staff were administering morphine to a person without this being recorded on their medicine's records...staff had not got clear instructions on when or how this was to be given”
critical“staff were applying people's creams without confirmation these were prescribed and these being recorded on people's medicines records. Staff had recorded applying unnamed creams to one person on 8 occasions.”
critical“Staff did not use the provider's E-MAR system or paper MAR charts to record the administration of medicines or creams.”
critical“No audits of medicines had been carried out since December 2019 and the provider had not been aware of the concerns we identified.”
moderate“audits regarding medication administration had picked up errors regarding medication however the actions taken to reduce the errors had not been completely effective.”
care planning
5 findings
critical“one person had a pressure area on their skin and had no guidance in place to support staff to meet this need. This placed them at risk of not receiving care in line with this need”
critical“people with diabetes had no care plans and risk assessments in place to reflect this...staff did not have clear guidance on how to identify signs of deterioration”
moderate“a person living with dementia had no reference to this within their care plan to ensure staff understood how this impacted the person and how they were treated.”
critical“One person's pre-existing assessment had not been reviewed since they were referred to the service in January 2020.”
minor“the movement and handling risk assessment had not been updated to give clear instruction to care workers regarding the additional risks involved in assisting the person to undertake gentle exercise.”
governance
4 findings
moderate“further improvements were still required to ensure the systems were well established and that governance processes could be used to provide regular oversight into the overall quality of care provided.”
critical“there was no oversight of how medicines records are completed and maintained...The provider had no system in place to monitor people's care records to ensure these remained accurate”
critical“Systems to monitor and assess the quality and safety of the service were not effective and had resulted in breaches of the regulations.”
moderate“The provider's call monitoring system was limited to sending an email alert for each individual call. This meant the provider did not monitor punctuality across the service.”
record keeping
3 findings
critical“staff were not always clear on the amount of thickener this person required to support them to drink safely. This placed the person at increased risk of choking.”
critical“Medicines administration records had not been completed since December 2019 and a mixture of electronic and paper-based records were being used.”
moderate“medication administration records (MAR) completed by care workers between April and July 2017 contained gaps in the MARs. The gaps in the MARs meant it was not clear if people had received their medicines as prescribed.”
incident learning
2 findings
critical“the provider had failed to review all alerts and take action to ensure improvements were made...a person had 2 alerts that had not been actioned on their care records in relation to their skin integrity”
moderate“Whilst the provider told us investigations were carried out and learning shared with staff, they were unable to provide evidence to support this.”
person centred care
2 findings
moderate“a person's care plan advised staff were to prompt the person with their medicines but not to administer them. However, staff were recording they had administered these medicines. This did not promote their independence.”
minor“People did not always receive personalised care that met their preferences; care calls were not always at their preferred times or delivered by consistent care staff.”
missed or late visits
2 findings
moderate“They should come at 8am but they sometimes don't come till 11am and at night they don't get here till 11pm, when they should be here at 9pm.”
moderate“Care calls were not always planned to allow travelling time, which meant staff frequently ran late and people sometimes felt their care was rushed.”
complaints handling
2 findings
critical“They discovered a misfiled complaint when searching for other records we requested. This did not assure us that complaints were consistently recorded.”
moderate“The provider did not record informal complaints or grievances and told us they were unaware of the complaint raised with us.”
safeguarding
1 finding
critical“The provider did not always notify CQC of potential safeguarding incidents at the service as they were required to do so. For example, we found 2 safeguarding referrals the provider had not notified us about.”
communication with families
1 finding
moderate“People's communication needs were not always recorded within their care records...having no guidance in place...placed people at risk of not consistently receiving care in line with these”
leadership
1 finding
moderate“The provider was struggling to balance the demands of managing the safety and quality of the service, whilst regularly covering care calls.”
staffing levels
1 finding
moderate“The provider did not have a systematic approach to determining the number of staff needed to maintain a consistently reliable service.”