critical“The provider did not have a comprehensive approach to auditing the quality of the care being provided. Where auditing was in place it had not been followed through to ensure improvement were made.”
moderate“It was evident that the monitoring of such records had failed to identify shortfalls within them. Care records were not up to date, medication records were not completed accurately.”
moderate“improvements weren't always clearly recorded, and it wasn't always evident how the registered manager had improved care as a result of identified issues.”
medication management
3 findings
moderate“We checked medication audits and saw these were completed every month. Where concerns were identified we saw that actions had not been completed.”
critical
“'[person's name], prescribed paracetamol that is not on MAR chart, carers have been administering them without the correct MAR chart.'”
moderate“When we checked the medication administration records we found these had not always been completed.”
incident learning
2 findings
moderate“Two consecutive audits identified the same concerns for one person. The action plan did not include dates for the work to be completed by and staff agreed these actions had not been followed up.”
minor“There was no evidence to suggest that the complaints that had been received, had been used as an opportunity for learning or service improvement.”
communication with families
2 findings
moderate“A relative told us of several occasions when a message had not be relayed to the staff relating to the person having an appointment. This meant the person did not receive the service they required.”
moderate“The management is very tacky, with no communication. I don't want to change care company because the carers are so brilliant, I just want them to be better organised.”
missed or late visits
2 findings
moderate“Staff had five minutes to travel to each support visit...on occasions this was not sufficient time...we saw records which confirmed people did not always receive the full time allocated.”
minor“They don't always tell me who to expect, they aren't always on time.”
record keeping
2 findings
critical“It was evident that not every visit had been recorded. This meant that there was a risk that these visits had not taken place.”
minor“one person's wishes regarding DNAR were not clear in their plan. The registered manager told us this would be updated immediately.”
complaints handling
2 findings
moderate“The provider's complaints procedure had not been followed because the registered manager had not responded to a complainant appropriately or within the timescale stated.”
minor“Some people told us they didn't receive responses to concerns raised.”
person centred care
2 findings
moderate“One person receiving nine different carers to provide 14 calls in one week... inconsistency of support workers was a concern to people.”
moderate“Harmony, however, well, the organisation is abysmal, they don't let you know who's coming, and that leaves you feeling very vulnerable.”
consent capacity
1 finding
moderate“There was no information to show the provider completed assessments to confirm decisions were made in people's best interest when they lacked the capacity to do so.”
care planning
1 finding
moderate“Plans of care were in place but not always up to date or accurate... one person had been provided with an extra visit in the evening, though this had not been included in their plan of care.”