critical“At the last inspection we found there was a breach of Regulation 12...people were not protected against the risks associated with medicines because the provider did not always have appropriate arrangements in place to manage medicines.”
critical“We found the systems in place to manage and monitor people's medication were not robust and there was a risk people may not receive their medication as prescribed.”
critical“The MAR charts did not list the medication prescribed, when they must be given, what the dose was or any special instructions.”
critical“We saw there had been seven medication incidents or errors in the last six months. On some occasions medical advice was not always sought.”
critical“Staff we spoke with were given inconsistent responses... One staff member said they followed instructions written on a notice board in a person's home.”
governance
2 findings
minor“The registered manager said they also checked daily notes to monitor call times and duration of calls, this was not fully documented either.”
moderate“The medication audits we looked at were not effective and had not identified the concerns we found at this inspection.”
safeguarding
1 finding
critical“some concerns raised had been addressed as complaints and conduct issues and had not been recognised as safeguarding matters. The registered manager had not reported these incidents to the local authority or to CQC”
consent capacity
1 finding
critical“care and support plans did not include an assessment of people's mental capacity to make decisions...This was a breach of Regulation 11, Need for consent”
care planning
1 finding
moderate“One person who had diagnosis of dementia had nothing in the care plan about the ways in which they communicated...Another care plan had not been updated when the person's circumstances changed.”
record keeping
1 finding
moderate“care plans for people who used the service did not all have an up to date list of medication that people took”
person centred care
1 finding
moderate“Records we looked at did not show how people who used the service were involved in identifying their care preferences...None of the care records we looked at had been signed by people who used the service”
missed or late visits
1 finding
moderate“some people said the call times were not adhered to as the majority of staff relied on public transport which meant they were frequently late and then rushed”
supervision appraisal
1 finding
moderate“some staff had received one to one supervision on a monthly basis, some on a quarterly basis and others who had not received a documented one to one supervision for over six months”
staff competency
1 finding
moderate“despite having received training, staff had a limited understanding of the MCA and how this affected their work...another staff member asked what the MCA was”
incident learning
1 finding
minor“The registered manager monitored any accidents or incidents... however, there was no documentary analysis of incidents to identify any patterns or trends.”
complaints handling
1 finding
minor“The registered manager did not have a system in place to carry out an analysis of complaints to look at any emerging themes.”