moderate“Codes signifying that people did not have their medication were not investigated. This meant that some inconsistency in medicines recording were not always identified.”
critical“Staff were dispensing medicines for people to take later and signing the MARs with a 'P'...no risk assessment in place to support this practice.”
critical“There were gaps in people's MARs...some gaps had no explanation. This meant that people may not have had their medicines on some days.”
critical“People's medicines administration records were not always clearly updated with changes. This had contributed to two medicines errors.”
moderate“People who had been prescribed medicine to be given using a patch did not have a record for staff to know where on the body the patch had been applied.”
critical“Medicines were not always managed safely. Processes in place did not clearly identify the level of support that people received with their medicines.”
critical“We saw gaps on people's MAR's which made it hard to ascertain if the person had received their medicines or staff had forgotten to sign.”
critical“One person's MAR was being signed by staff but it had no recorded medicines on it, instead it just stated the month 'November'”
governance
5 findings
moderate“We saw audits in place to monitor medicines management were not always robust.”
critical“Audits had not identified some gaps and inappropriate practices in relation to medicines administration.”
critical“There was no evidence of analysis of medicines errors and a review of what had happened and why. There was no evidence of reflective practice for the staff.”
moderate“Completed audits had not identified all of the concerns we found at this inspection. One audit review stated that care plans needed to be more detailed. However, this audit had no date.”
critical“We had not been notified of the three safeguarding alerts made to the local authority by the registered manager... breach of Regulation 17(2)(a),(b),(d) of the Health and Social Care Act 2008”
record keeping
4 findings
moderate“Management of complaints had not been sufficiently recorded, this meant that we were unable to assess whether these had been handled appropriately.”
critical“Systems were not in place to check the accuracy of transcribing medicines information onto the providers electronic system. This had led to a medicines error.”
moderate“Some risk assessments were incorrectly completed and this had not been identified during reviews.”
minor“One care plan stated 'currently being hoisted. The registered manager told X is unable to move, but they are able stand for a wash and should have been updated.'”
staff competency
3 findings
moderate“Other staff told us they didn't understand the principles of the Act and couldn't remember if they had received training in this area.”
moderate“Staff had not all been shown how to apply topical creams or eye drops. There had also been no competency checks for this type of medicines administration.”
moderate“We were told that the district nurse had provided the training to staff on how to manage the catheters, however there were no records to confirm this.”
safeguarding
2 findings
critical“The provider had not submitted one statutory notification in relation to safeguarding concerns...breach of Regulation 18 (2)(e).”
critical“We had not been notified as required of safeguarding alerts made to the local authority.”
incident learning
2 findings
moderate“There was no clear overview and analysis of accidents and incidents used to identify possible trends or patterns.”
moderate“There was no evidence of analysis of medicines errors and a review of what had happened and why. There was no evidence of reflective practice for the staff.”
missed or late visits
2 findings
minor“People consistently raised that the times of visits were varied and this caused frustration. 'They don't come at a set time unfortunately, but they do always come'”
critical“There was no robust system for missed or late calls, relied on staff or the person informing the office.”
complaints handling
1 finding
minor“We saw no formal record of response to complaints the service received...responses were done verbally either via phone call or face to face.”
consent capacity
1 finding
moderate“At times the service had accepted decisions made by relative's who did not have the appropriate legal authority to make that decision or consent on a person's behalf.”
care planning
1 finding
moderate“We found there was a lack of person centred detail in some of the plans. The majority of people's care plans were written on one page and some were very brief.”
person centred care
1 finding
minor“The information did not identify the individual as a person in their own right with specific wishes and preferences.”
staff training
1 finding
moderate“We saw two systems for recording training, one paper and one computer based. The two systems didn't correlate; this resulted in us being unable to confirm that all staff had undertaken the training necessary.”
supervision appraisal
1 finding
moderate“Despite this, supervision records were not always in place for all the meetings which had taken place.”