critical“Systems were not in place to guide staff in safely administering 'as required' medicines...This put people at risk of not receiving their "as required" medicines safely.”
moderate“information was not always recorded to guide staff in relation to the area this had been applied to so they can ensure correct rotation of the patch.”
critical“The provider had not put additional safety measures in place to ensure medicines being transcribed on the electronic system were accurate by being counter checked.”
moderate“There had been 12 medicine errors in the previous nine months. The medicine errors were all recorded and lessons learnt to stop them from happening again.”
record keeping
3 findings
moderate
“Environmental risk assessments of people's home were not consistently available on the electronic system or lacked detail.”
moderate“Environmental risk assessment of people's home were carried out as part of the pre-assessment process, but were not consistently available on the electronic system.”
minor“a full employment history had not always been obtained following changes to recent recruitment documents”
governance
3 findings
critical“The systems implemented by the provider to help monitor the service had not always been effective in identifying and addressing quality and safety shortfalls in the service.”
moderate“there was no system in place for documenting and auditing the findings in relation to care calls; including punctuality, cancelations and calls outside planned times.”
critical“Audits and management systems had not identified concerns we had found at this inspection in relation to recruitment, risk management and care plans, medicines and assessments of mental capacity.”
care planning
2 findings
critical“the support requirements for one person with epilepsy had not been identified and recorded. Therefore, staff may not fully understand how to support the person safely”
critical“The assessment and support requirements for one person with diabetes had not been identified and recorded. Therefore, staff may not fully understand how to support the person safely.”
staff competency
2 findings
critical“recruitment records did not always show that the recruiting managers had explored the previous employment histories of staff and their suitability to work at in the service.”
critical“Safe staff recruitment practices were not in place to reduce the risk of unsuitable staff from being employed.”
communication with families
1 finding
minor“mixed feedback from people and their relatives in relation to the communication with the office, such as not knowing who the manager was, who to contact and not always being contacted back.”
supervision appraisal
1 finding
moderate“further development was required to ensure there was a system in place which provided a clear overview of staff's mandatory training”
consent capacity
1 finding
moderate“Care documentation did not always clearly evidence people's mental capacity particularly in relation to decision specific areas such as support with medicines administration.”
incident learning
1 finding
moderate“The registered manager had identified that some improvements were needed...monitoring of accidents and incident. However, auditing process had not been effective in identifying improvements required.”
missed or late visits
1 finding
minor“Three people we spoke with told us that staff were often later than planned but they would always turn up eventually and they would be told in advance if this was the case.”