moderate“one person was prescribed a PRN named Buscapan (for painful stomach cramps), but the strength, dosage and when to give were not recorded on the MAR chart.”
moderate“Medicines had not always been recorded adequately and action required had not always been taken.”
critical“MAR sheets did not list individual medicines, prescribing instructions and were not signed in. Carers recording 'dosette box' with no record of contents.”
staffing levels
2 findings
moderate“visits were not always scheduled to allow staff time to complete the required care and support, and also to travel from one person to the next.”
critical
“Staff members were not paid for travel time...one care call is from 08.00-08.30 and the next call for that staff member will be 08.30-09.00.”
missed or late visits
2 findings
moderate“evening is hit and miss, they always arrive but can come as late as 9.30pm when it was meant to be 7.30pm. It is very late for my father”
critical“50 care calls were delivered more than an hour later than the agreed time. 11 were more than an hour and a half late, with some being over two hours late.”
governance
2 findings
moderate“the audit and records had not been robust enough.”
critical“Quality audits had failed to identify several shortfalls: care plans not updated for over two years, risk assessments partially blank, medicines systems not safe.”
record keeping
2 findings
critical“Gaps between staff education and employment histories were not fully explored in two out of four files reviewed.”
moderate“One person's care plan had not been updated in over two years. Risk assessments had several parts left blank with no mention of mobility issues.”
staff competency
1 finding
critical“The provider had not always followed effective recruitment procedures to check that potential staff employed were of good character and had the skills and experience needed.”
communication with families
1 finding
minor“people and care staff told us they were not satisfied with communication with office staff.”
care planning
1 finding
critical“Some people's care had been commenced without a pre admission assessment meaning that carers were supporting people without a care plan in place.”
person centred care
1 finding
moderate“Care plans were not consistently person centred and did not always contain the detailed personal information required to support someone in a person centred way.”
consent capacity
1 finding
critical“Bedrails were being used with no capacity assessment. Care plans contained references to mental capacity but lacked an underpinning assessment.”
safeguarding
1 finding
minor“The training programme did not contain any provision for safeguarding children.”
staff training
1 finding
minor“The training manager told us that as the service only supports adults they do not cover safeguarding children in their training programme.”