minor“there were no guidance in place to support staff with administration of 'as and when required' medicines.”
critical“Not ensuring people received their medicines as prescribed was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“staff were not always recording this consistently on the MARs, increasing the risk of medicines errors... there continued to be some medicine errors, including a more serious one in recent weeks”
minor“As the service supported over 200 people the sample size used was not large enough to give an accurate representation of the service's performance in this area.”
record keeping
4 findings
minor
“There were some shortfalls within care records to identify people's assessed needs.”
minor“records for two staff recruited in recent weeks, contained only one written reference”
critical“People were not always protected from unsafe care because risks to their safety and wellbeing were not always identified and accurate and up-to-date records were not maintained.”
moderate“The quality assurance advisor told us they did not review people's care plans when assessing the log books which meant they were not able to assess if staff had delivered all of the care.”
care planning
3 findings
minor“Some documents required updating so this was fully captured in care planning. The registered manager assured us this action would be taken.”
moderate“some care plans contained minimal directions for staff to provide support in areas such as personal care, catheter care, meals and mobility whereas other care plans were much more detailed.”
moderate“where people's care records identified staff were providing care to prevent pressure damage, there was no assessment completed to identify the level of risk”
governance
3 findings
critical“The registered provider did not have effective quality monitoring arrangements in place. This was a breach of Regulation 17 of the Health and Social Care Act 2008.”
moderate“systems were not in place to review key data including spot checks, supervision and training, complaints, incidents and accidents to identify any learning”
moderate“Further improvements were required to ensure the governance systems could effectively and consistently drive improvements across the service.”
supervision appraisal
2 findings
moderate“Records showed all the care co-ordinators and approximately 30% of the care workers had received supervision in recent weeks.”
moderate“Staff did not receive effective levels of professional support... records showed a high percentage of the staff required an annual appraisal.”
incident learning
1 finding
moderate“Information from incidents and complaints was not reviewed to identify any trends or themes.”
consent capacity
1 finding
minor“people's capacity to make decisions was not considered and recorded within the assessment and care planning process which the registered manager confirmed they would address.”
missed or late visits
1 finding
minor“Records showed there were some incidents of missed calls... one person told us their additional care worker had not turned up that morning and they had not been given any explanation”
complaints handling
1 finding
minor“Complaints received since our last inspection were not always responded to in the 28 day time frame stipulated in the policy.”