moderate“there continued to be medicine errors involving the same staff member, which had not always resulted in referrals being made to the local authority safeguarding team.”
critical“This person mistakenly took an overdose yet the service reassessed the risks associated with their medication administration five months later.”
critical“The records for a second person gave contradictory information on whether medications had been administered. Crosses on their MAR chart over a four-day period indicated that a medication...had not been given as prescribed.”
governance
2 findings
critical“some action points rolled over from one meeting to the next, rather than being actioned within agreed timescales.”
critical
“Effective systems and processes were not in place to assess, monitor and improve the quality and safety of the care provided. Regulation 17 (1), (2) (a), (b), (c)”
incident learning
2 findings
moderate“Greater levels of analysis of incidents and accidents continued to be required, to ensure themes and trends were consistently identified, and onward referrals made”
moderate“An accident and incident log was in use, however there were no entries in the log relating to medication errors.”
supervision appraisal
2 findings
moderate“records showed some staff supervision and spot checks moved from one month to the next, which did not ensure consistent oversight of performance.”
moderate“Staff confirmed they received written updates in the form of memos but said they had supervisions infrequently. It was recognised by management that a more structured approach to regular supervisions and the introduction of appraisals was needed.”
safeguarding
2 findings
moderate“medicine errors involving the same staff member, which had not always resulted in referrals being made to the local authority safeguarding team.”
critical“During our inspection we identified an incident that was a potential safeguarding concern...the registered manager also acknowledged that two medication errors...should also have been referred.”
record keeping
2 findings
minor“the timeframes for this ranged from between three and nine months. This did not ensure that staff always had access to current information.”
critical“A box of unchecked task sheets contained sheets dating back to March 2018. A member of staff told us the reason for this was that they didn't have time to look at them.”
staff training
2 findings
moderate“Greater provider level oversight was required to monitor the completion of staff mandatory training...the service had more than one version of their training matrix”
moderate“Three members of staff had not undertaken training on the Mental Capacity Act and two had not undertaken emergency first aid training. Re-training...was overdue for six members of staff.”
care planning
1 finding
moderate“Care plans failed to consistently contain person centred information. This put people at risk of receiving care that did not meet their needs in the event they were supported by agency staff.”
consent capacity
1 finding
moderate“Neither person had had a mental capacity assessment to determine their level of capacity...No best interest decisions had been taken for either person.”
end of life care
1 finding
moderate“We did not see details in people's care files about their preferences relating to end of life care...we reviewed the file of a person who was being given palliative care and there were no records relating to their end of life care preferences.”
communication with families
1 finding
minor“The registered manager acknowledged that they needed to re-assess the communication skills of a person who did not speak English as their first language. The person's relative had been required to interpret.”