critical“Staff did not administer medicines against an accurate medicines administration record [MAR]. The list of tasks used did not contain all the information about the medicines prescribed.”
critical“Another person had not received their prescribed medicine as it had been withheld because the staff member thought it should be given at a different time.”
critical“Medicines were not being managed safely. The service told us they did not support people with medicines. However, two staff we spoke to told us they supported people with medicines such as taking the medicines out of blister packs.”
critical“staff were administering medicine to people without consent and not recording administration on Medicine Administration Chars [MAR]”
governance
4 findings
critical
“Care plan audits had been carried out. However, these audits did not identify the shortfalls we found with ensuring accurate records were kept on risk assessments.”
moderate“Medicines audits...had identified some shortfalls...Whilst an action plan had been completed, the required actions had not been fully completed at the time of the inspection.”
critical“There was lack of robust audit systems in place to identify shortfalls and take prompt action to ensure people received safe high-quality care.”
critical“effective quality assurance systems were not in place to identify the shortfalls we found during the inspection”
care planning
3 findings
critical“Risk assessments had not been completed in relation to people's health conditions...Staff did not have information about signs and symptoms of risks.”
critical“Care plans were not person centred and lacked details on people's support needs... information on some care plans indicated that staff should support people with personal care without including the type of personal care required.”
critical“risk assessments had not been completed for people with identified risks to ensure they received safe support at all times”
missed or late visits
2 findings
moderate“Staff monitoring data showed a number of calls had not been attended on time with a number of calls being over 45 minutes late.”
moderate“On occasions staff had not logged into calls therefore could not be assured that care had been delivered during this time.”
person centred care
2 findings
moderate“There were inconsistences in recording people's preferences on how they would like to be supported with personal care such as with bathing and showering.”
moderate“Robust pre-assessments systems were not in place to ensure people received support in a person-centred way. Care plans were brief and were not person centred.”
record keeping
2 findings
critical“The failure to maintain accurate, complete and contemporaneous records for each service user meant that service users were at risk of receiving unsafe and inappropriate care.”
moderate“Some daily logs did not include the person's name or date of birth, which meant it would be difficult to identify the person who received that support.”
consent capacity
1 finding
critical“Assessments had not been completed to determine if people had capacity using the MCA principles... The service had not sought consent from people prior to delivering care and support.”
staff training
1 finding
critical“Four staff had not completed key training to perform their roles effectively. One staff member last completed training in 2012 when working for another care agency.”
supervision appraisal
1 finding
moderate“Regular supervisions had not been carried out in accordance with the provider's supervision policy. Some staff, recruited in November and December 2018, had only received one supervision.”
safeguarding
1 finding
moderate“The provider's safeguarding policy was last updated in October 2016. The policy did not include the types of abuse and who staff could report to externally other than the police.”
cultural competency
1 finding
minor“On two referral forms people's religion had not been included... both people were from a specific religious background and may have had specific preferences about the support they received.”