critical“One person was prescribed medicine for their diabetes twice a day, however staff were administering this three times daily. This placed them at risk of harm.”
critical“One person was prescribed ibuprofen 200mg. However, this had been recorded on their medicines records as 500mg. Staff had signed to say they had administered this dose.”
critical“One person was prescribed medicine for pain relief which required doses to be spaced 12 hours apart. However, they did not always receive this medicine at the correct time.”
moderate“When people received their medication via a trans-dermal patch the provider had failed to ensure there was sufficient guidance in place around where patches should be placed.”
critical“One staff member was sent out and expected to administer medicines to two different people, however they had not been trained to carry out this task.”
critical“Some people's medicines were administered without the correct recording documentation in place. This included prescribed creams and pain relief.”
record keeping
4 findings
critical“People did not always have doses of medicines recorded on the medicine records. This meant there was not always guidance in place for staff to ensure people received their medicines as prescribed.”
moderate“some plans referred to other people's names and needs so we could not be sure they were always personalised. This had not been identified by the provider.”
moderate“provider acknowledged the records did not fully reflect the actions they are taking”
critical“Staff who completed the medicine audits had amended administration records, so it showed people had received their medicine. Some of these records were amended over six weeks later.”
governance
3 findings
critical“Quality assurance systems were not effective at identifying concerns or areas for improvement therefore the provider could not demonstrate they were continuously learning.”
moderate“there were still areas where systems and processes used did not evidence all the work undertaken. For example, the training records and recruitment records.”
critical“Although audits were completed on people's care and records, they had not identified the concerns and errors we identified.”
staff training
3 findings
moderate“Staff did not always receive sufficient training to be effective and feel confident in their role.”
moderate“staff members were completing excessive courses in 1 day and the records did not make it clear when competency assessments had been completed”
critical“Staff completed 22 care related topics in one day... Records showed staff also completed the Care Certificate on the same date. Some staff told us they had no recollection of having completed this course.”
communication with families
3 findings
moderate“The communication is a nightmare I'm sorry to say. If I phone and ask them for something, they say they'll call you back and they never call back.”
minor“a number of people told us there was an occasional language barrier, especially with new staff but all staff were polite”
moderate“Telephone calls made to the provider's Stoke-on-Trent office were diverted to their office in Bangladesh. The registered manager had not informed people or relatives about this.”
safeguarding
2 findings
critical“one person had bruises and a possible bite mark which had not been checked on...staff had reported concerns about family members allegedly abusing people.”
critical“Staff administered one person's medicine without leaving the required time gap between dosages. This posed a risk of harm to the person. We reported this to the local safeguarding team.”
missed or late visits
2 findings
critical“one person who had double-up calls was visited by 50 different staff in a one-month period.”
critical“Some people received calls lasting just one, three or 13 minutes when they should have 30 minutes. There was no information to state why people did not receive their full amount of time.”
staffing levels
2 findings
critical“There were not enough staff to safely cover every person's planned calls, particularly those who needed two staff to attend each call.”
critical“Staff told us there were insufficient numbers of staff to meet people's needs. One staff member told us, 'They are taking on too many clients for the staff to cope.'”
incident learning
2 findings
moderate“The record of the investigation was poor, with lack of detail about what had gone wrong and what had been investigated.”
moderate“Despite actions taken in response to incidents we were not assured the provider had learnt lessons... specific and individual actions taken but these did not feed into the wider service to help identify themes.”
consent capacity
2 findings
minor“some people who had relatives recorded as either giving consent...without the relevant legal authority being evidenced.”
critical“One person lacked capacity to consent to their care. Best interest decisions had not been made and the management team did not know whether or not the relative had the lasting power of attorney.”
staff competency
2 findings
moderate“records did not make it clear when competency assessments had been completed. The provider spent time showing us how they managed training”
moderate“Not all staff who supported people with a learning disability had received appropriate training. The registered manager told us they were currently developing a training session.”
person centred care
2 findings
minor“Not all people had received them yet but of those which had been completed, the feedback did reflect the positive changes over the past 6 months.”
moderate“People's protected characteristics, as identified in the Equality Act 2010 were not always outlined in their care plans. This included gender, age, culture, religion, ethnicity and disability.”
care planning
1 finding
critical“Some people had catheters with no plans in place to help staff provide safe catheter care... Some people's care plans did not identify they even had a catheter.”
infection control
1 finding
moderate“Six of these staff did not change their mask in accordance with the current Government guidance. This placed people at risk of catching infections, such as COVID-19.”
supervision appraisal
1 finding
moderate“The area manager acknowledged staff supervision and observation of their practice had not been completed regularly but they were now getting back on track with these.”
leadership
1 finding
critical“Since the provider registered with us in 2015, we have inspected them nine times. On only one inspection have they been rated as good.”