critical“There were insufficient staff employed at the service to ensure people received their care in a timely way. The provider had contacted them to hand back five packages of care.”
missed or late visits
1 finding
critical“Staff told us some staff had left and calls were sometimes late or had occasionally been missed. The provider confirmed that some calls had been missed or staff had been late.”
medication management
1 finding
critical“Medicine that should have been administered the previous day was still in the blister pack and a member of staff had signed the MAR to say that the person had received their medicines.”
staff training
1 finding
critical“Staff told us they had not received any training to administer medicines whilst working for the provider. No reference to training in the Mental Capacity Act and associated DoLS.”
governance
1 finding
critical“The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service. No system to monitor for missed calls.”
consent capacity
1 finding
moderate“The assessment stated that there was no lasting power of attorney in place, which meant the person's relative did not have the legal authorisation to make decisions on their behalf.”
supervision appraisal
1 finding
moderate“Some staff told us the registered manager had begun to hold supervision meetings with them, although the arrangements were not formal and there was no set agenda.”
safeguarding
1 finding
moderate“One member of staff was not aware of how to escalate their concerns to the local safeguarding team if they felt appropriate action had not been taken.”
record keeping
1 finding
moderate“There were no checks carried out on the daily logs staff completed. One person's record did not have an entry for two of their calls and there was no evidence the provider monitored these records.”
incident learning
1 finding
moderate“Notifications of important events that occurred in the service were not always sent to us. The provider did not always notify us when concerns had been referred to the local safeguarding team.”
staff competency
1 finding
moderate“Staff knowledge and competency to fulfil their role was not checked by the provider. Registered manager's train the trainer qualification was not in safe moving and handling or medicines management.”