moderate“Some risk assessments had not been reviewed or transferred onto a new format which supported more comprehensive risk assessments. These risk assessments lacked the detailed information and guidance staff needed.”
minor“Call logs showed some staff were not staying the full duration of the visit... this was not recorded in call logs to support this decision.”
moderate“Where people had a Lasting Power of Attorney appropriate records were not always completed.”
moderate“The manager confirmed referrals were being made to the GP...however, they were unable to evidence due to lack of recording on internal electronic systems.”
minor“People's plans of care had not always been signed by the person or by the person's representative... neither the initial assessment or plan of care had been signed”
care planning
5 findings
minor“Care plans that were not in the new format lacked personalised information.”
moderate“Generic risk assessments were in place however they were not person centred.”
minor“Care plans did not record people's likes and dislikes in terms of nutrition adequately.”
moderate“not all the assessments seen included person specific information and were more generic in nature... one person's plan of care stated they should not be left with any hot drinks or anything sharp, this risk had not been identified”
minor“We saw that some reviews were overdue. The registered manager told us that the review meetings were booked for the coming weeks.”
governance
4 findings
minor“The registered manager undertook limited audits and checks to ensure compliance... Further developments to audits and checks would enable the registered manager to have more effective oversight.”
moderate“Quality assurance systems were not adequately in place to assess, monitor and improve the quality and safety of the service provided.”
moderate“The manager undertook quality audits...however, these audits did not always highlight gaps.”
moderate“Whilst systems were in place to monitor the quality and safety of the service, these had not identified omissions within some people's documentation.”
medication management
3 findings
critical“Medicines were not managed safely as staff did not sign to say individual medication had been administered.”
critical“Staff did not record why PRN ('as required') medicines were administered.”
minor“a recent audit had identified staff had not always signed the charts when they administered people's medicines.”
complaints handling
2 findings
minor“At the time of our inspection the provider did not have a system in place to identify themes and trends.”
minor“We identified that one complaint had not been logged and it was not clear how this had been dealt with.”
missed or late visits
2 findings
moderate“An example of this was people experienced missed calls. To mitigate this risk an electronic call monitoring app was in the process of being introduced.”
moderate“one member of staff said a person they had visited that morning, had not received their call the previous morning... they had missed a morning call and therefore not prompted to take their medicines”
person centred care
2 findings
minor“Care plans needed more personalisation. For example, they did not include information such as peoples likes and dislikes.”
minor“Some people told us that there were times when staff rushed them. One relative told us, 'The girls do not stay and seem in a rush to leave.'”
supervision appraisal
1 finding
minor“Although some staff had not received regular, formal supervision, staff unanimously said they could and did approach the office managers at any time.”
end of life care
1 finding
minor“The service had an end of life policy in place. However, care plans we looked at did not contain end of life wishes.”
safeguarding
1 finding
critical“the provider's safeguarding processes had not been followed and an allegation of concern had not been followed up in a timely manner... no immediate action had been taken to report the concern to the safeguarding team”
staffing levels
1 finding
moderate“one member of staff informed us they had been allocated to support a person on their own: the person had been assessed as requiring two staff members.”
consent capacity
1 finding
minor“Not all of the staff we spoke with could remember completing training in MCA but those that did, understood its principles.”
staff competency
1 finding
minor“Some people felt that newer staff did not have the life experience or skills to meet their needs. One person told us, 'The problem was that I got too many new staff every day.'”