moderate“The electronic systems used by the provider for monitoring some people's care visits were not always operated effectively.”
critical“Systems and processes to assess and monitor the safety and quality of the service were inadequate. Widespread concerns found with risk assessments and unsafe medicines practice were not always picked up.”
critical“Only 10% of records were audited each month and there was no pattern to these checks meaning there was no assurance that people's care plans and medication records were being audited.”
moderate“these auditing systems were in place they had not highlighted some of the issues we found during our inspection in relation to capacity, best interests and consent”
record keeping
4 findings
minor
“The medicines policy had not been updated to reflect the changes in how medicines were managed including the use of a new electronic medicines record.”
moderate“Training records were not well maintained. It was difficult for the registered manager to effectively monitor this.”
moderate“Audit processes had not identified missing, incomplete and inaccurate paperwork. Care records were incomplete and did not include evidence that people had made decisions.”
moderate“some care plans had not been signed by people, so we were not sure if they were able to consent to their care or if this would need to be a best interest decision”
care planning
4 findings
critical“Risk assessments were either not completed, not person-centred or not detailed enough to guide staff in supporting people safely.”
critical“Care plans for people with specific health conditions such as diabetes, asthma and reduced mobility did not contain risk assessments in relation to these areas.”
critical“Some people, including those with more complex needs, did not have a care plan in place. What paperwork was in place, did not always reflect their current care and support needs.”
minor“the information did not instruct staff with regards to how to manage the risk specifically for that person, it was generic”
supervision appraisal
3 findings
minor“Two staff members told us they often didn't get a response after leaving messages for a manager to contact them.”
moderate“We received mixed feedback from staff with regards to their ongoing support. Some staff felt unsupported. Records showed that many staff supervisions were out of date.”
moderate“"I have never had supervision, I come over in October" and "I am able to raise concerns, but don't feel like anything changes".”
communication with families
3 findings
minor“Staff told us communication with office staff including managers could be better. A member of staff told us they had emailed a manager several times requesting contact.”
moderate“People and staff told us that communication with office staff was poor. Comments included, 'One time I phoned up 15 times and couldn't get through'.”
minor“"[The service] did not call and tell me when they are going to be late. My daughter rang the office. They never rang back" and "They were 30 minutes late. No phone call."”
medication management
3 findings
critical“Medicines were not being given to people as prescribed. Two people who required a medicine to manage their health condition had not been given the correct dose on multiple occasions.”
critical“The required four-hour time interval between doses of paracetamol was not always observed so there was a risk of overdose.”
critical“There were several missing signatures in some people's MAR charts. Handwritten MAR charts were not always completed accurately, and medicine allergies were not recorded.”
consent capacity
3 findings
minor“Further improvements were needed in the consistency of the application of MCA processes. MCAs were completed when there were no concerns about a person's capacity.”
critical“The registered manager was not complying with the principles of the MCA. People's care records did not always evidence that people had been consulted and involved with their plans.”
moderate“one person was described as having capacity. However, when we looked at some of their other documentation there was conflicting information around the person's decision making ability”
incident learning
3 findings
critical“At the last inspection we found shortfalls with medicines management and risk assessments. Similar concerns were identified at this inspection. The provider had failed to learn lessons.”
moderate“There was no recorded oversight for identifying any trends and help prevent any future risk. We saw evidence of incidents of a similar nature occurring to the same people.”
minor“There was nothing documented to evidence where improvements were being made [from care concerns]”
missed or late visits
1 finding
moderate“Staff with oversight of the providers electronic system for monitoring any missed or late visits had not always identified and acted upon them.”
staff competency
1 finding
moderate“Not all staff had their competency to administer medicines assessed in line with best practice guidance. This meant there was a risk that medicines could be administered by staff that did not have the skills.”
leadership
1 finding
critical“There has been repeated failure from the provider to ensure the delivery of safe, high quality care. This is the second inspection the provider has failed to meet regulations.”
staff training
1 finding
moderate“Not all staff had received formal training in infection, prevention and control, including training specific to COVID-19. Staff had not completed all mandatory training, including medication.”
staffing levels
1 finding
moderate“At weekends there was insufficient time for staff to travel between calls meaning that staff arrived at their calls later than scheduled.”