critical“People medication plans were inaccurate and risk assessments were either absent or incomplete and did not fully consider the risks around people's medicines.”
minor“We did find a discrepancy for one person where the records were not accurate. The medication administration chart had not been updated when the persons medication had changed.”
critical“Medicines had not always been managed safely, because people had not always received their prescribed medicines.”
governance
3 findings
critical“The provider did not have a system for the collation of incidents to identify patterns and monitor safety related information.”
minor
“Further work was needed to embed some of the changes that had been made...whilst progress had been made there was still work to do to ensure processes are embedded.”
critical“The failure to operate effective quality assurances systems and properly assess, monitor and mitigate risks and ensure safety is a breach of regulation 17 (Good Governance)”
safeguarding
2 findings
critical“Incidents were not always recognised as safeguarding and therefore correctly reported internally and externally to the local authority safeguarding team where required.”
moderate“The service had not informed the Care Quality Commission at the time of a safeguarding incident which had been reported to the Safeguarding service.”
incident learning
2 findings
critical“Incidents and accidents forms were poorly completed, there was little information on how staff intervened in an incident or what techniques they used to defuse the situation.”
moderate“Good governance of the service had not always been achieved or the experience of lessons learnt applied across the whole service.”
missed or late visits
2 findings
moderate“Staff told us that they had regular rota changes and shortfalls meant that they were cutting visits short and arriving late to support people.”
moderate“Prior to the inspection there had been issues with the scheduling of calls for people receiving a domiciliary service due to a failure of the electronic planner. This had led to some people missing their visits.”
care planning
2 findings
moderate“Care plans were inconsistent in quality and level of guidance provided to staff...plans did not contain the level of detail they needed to support people.”
moderate“Information in care plans was not always easy to find as they did not all have an index or profile...End of life sections of care plans had not been completed.”
staff training
2 findings
moderate“Staff supporting people with health conditions such as Parkinson's and Multiple Sclerosis did not have training in this area.”
moderate“We identified continued shortfalls in staff knowledge and understanding of behaviours as an expression of anxiety and mental health.”
person centred care
2 findings
moderate“People did not receive care that was planned to be person centred, proactive and well-co-ordinated. They were not always supported to have meaningful lives.”
minor“There were still some examples of task based practice...objectives would benefit from being more clearly documented to ensure more consistency and measurable achievements.”
end of life care
2 findings
moderate“One person had been identified as being at the end of their life but there was no end of life plan in place.”
moderate“End of life sections of care plans had not been completed but there were details of any funeral plans in place...documentation was not being stored consistently.”
complaints handling
2 findings
minor“There was not always a correlation between what concerns people told us that they had raised and the records at the agency.”
minor“Others were not yet confident that raising concerns would lead to change, as they had poor previous experiences. Further work is needed to improve trust with relatives.”
staffing levels
1 finding
critical“The service did not have sufficient numbers of staff in either the domiciliary or the supported living service to meet the needs of the people they supported.”
consent capacity
1 finding
critical“People's rights under the Mental Capacity Act had not always been respected and the act was not fully understood.”
record keeping
1 finding
moderate“Staff did not always complete the handover forms, so it was not clear who was supporting who and when. Clearer accountability was necessary.”
infection control
1 finding
moderate“Areas including food preparation areas were not always clean and staff did not always fully understand their responsibilities to support people to maintain a clean environment.”