moderate“medicines audits are not monitored in 'real time' so they were unable to respond quickly to missed medicines unless they are alerted to this by staff at the next call.”
minor“competency assessments were not being reviewed as regularly as recommended by the National Institute for Clinical Excellence (NICE) guidance.”
minor“There was no additional information available for staff to let them know the amount of tablets in the pack or what the tablets were.”
moderate“On one MAR that had been checked we found errors that had not been identified. There was no staff signatures on some medicines to show these had been given as prescribed.”
record keeping
3 findings
critical
“Risks to people were not always fully assessed and mitigated. For example, falls risk assessments did not always give enough detail for staff to know how to mitigate the risks”
minor“where these referenced our regulations they referred to the previous Health and Social Care Act not the amended 2014 Act, and associated key lines of enquiry.”
minor“Some people with care plans for the prevention of skin damage did not have risk assessments completed to show they were identified at risk of developing skin damage.”
governance
3 findings
critical“This was a breach of regulation 17(1)(2)(a)(b)(c)(d)(f) — provider did not fully use governance systems and processes to record information needed to keep people and staff safe.”
minor“comments made by people during telephone surveys and on the annual postal survey were responded to and recorded on the person's individual file. As this information was not centrally collated the actions taken were not easily available.”
moderate“Information was not collated to show how many late or missed calls had occurred, or if there were any trends or patterns and if improvements could be made.”
incident learning
2 findings
moderate“Audits were in place but we found actions were not always taken, for example the call times audit identified some staff always made use of the 5 minute leeway to leave calls early”
moderate“It was not clear there had been any learning or trends identified from complaints received to help prevent them from happening again.”
missed or late visits
2 findings
moderate“Sometimes they can be three hours late at a weekend. They come to do my tea but they don't get here until after 8pm sometimes, far too late.”
moderate“The company were not aware of the no shows until I contacted them each time.”
complaints handling
2 findings
moderate“The last entry in the book we were shown was 2014...the provider did not have an overview of the concerns and complaints people had raised.”
moderate“There was no evidence that complaints had been logged and investigated in line with the provider's complaints procedure.”
care planning
2 findings
moderate“There is a care plan but it is very out of date. Her needs have changed and what they do now isn't in the care plan.”
moderate“Three care plans we looked at had not been reviewed within the last 12 months in line with the provider's procedures.”
safeguarding
1 finding
critical“incidents that related to care of people identified during the disciplinary process had not been referred to the local authority safeguarding team or CQC”
supervision appraisal
1 finding
moderate“Staff supervisions and training had also lapsed but this had been addressed by the time we carried out the site visit on 03 August 2022”
leadership
1 finding
critical“This was a breach of Regulation 19 (Fit and Proper Persons Employed) — provider did not have a suitable disciplinary policy in place and decisions were inconsistent.”
communication with families
1 finding
minor“I have spoken to Meadows home care. I've had problems with them not calling back. I will leave a message, when they do finally get back, they are helpful.”
staff competency
1 finding
minor“the registered manager was unable to provide evidence that the NI had an up to date 'train the trainer' qualification to provide this in line with good practice guidelines.”
staff training
1 finding
minor“Training that had not been renewed in line with the providers timescales included, food hygiene, first aid and health and safety training.”