critical“There were not always processes to identify where action may be needed to reduce the risk of abuse. No assessment of possible risks had been completed. There was no risk management plan in place.”
critical“Care records showed staff used restrictive practice in relation to another person, which placed them at risk. Appropriate legal processes had not been followed in relation to this.”
critical“staff were not following the safe moving and handling practices they recommended for one person. This could place them and staff at risk of injury. We raised this as a safeguarding alert.”
medication management
3 findings
critical“Staff were not administering medicines in accordance with the health professionals' instructions. Where medicines were prescribed to be administered before eating staff were routinely administering them after food.”
critical“a pain patch prescribed to be administered every 72 hours was not always administered according to these instructions and longer gaps were recorded.”
critical“no detailed risk assessment in relation to administering medicines via PEG feeding...did not guide care staff to identify and assess risks in relation to medicines administration.”
governance
3 findings
critical“Their system of quality monitoring did not identify the concerns and breaches of regulation we found. There were no care plan audits to identify the issues of discrepancies and contradictory information.”
critical“Systems to monitor the quality and safety of the service were not effectively operated. The provider had not identified that missed support alerts were not always resolved on the day.”
critical“shortfalls in the systems to oversee call monitoring, oversight of medicines and risks...Audits carried out did not identify these concerns.”
care planning
3 findings
critical“Care plans and assessment records we viewed contained contradictory information about how people should be safely transferred which placed people at risk of staff following the wrong information.”
moderate“Three people and their relatives told us they had not seen a written care plan for the support provided. One relative remarked, 'We have not received a written care plan since we commenced having carers several months ago.'”
moderate“one person's catheter risk assessment did not identify the possible risks to alert staff or record when issues should be reported to district nurses.”
record keeping
3 findings
moderate“Records such as a list of all employees were not readily available when inspectors requested on the first two days of inspection. We found discrepancies in staff records.”
moderate“Live-in care plans were not robust and did not provide clear guidance on the tasks and expectations of staff at night.”
moderate“discrepancies in staff training records...Some staff were recorded as delivering a full day of care visits on the same days they were recorded as completing multiple training courses.”
leadership
3 findings
critical“The registered manager did not always have an up to date picture of people's needs. About half the people we spoke with were not sure who the registered manager was.”
moderate“The registered manager had told us they had obtained consent for our calls to people as part of the inspection. However, of the 13 people spoken with no one had been asked for their consent.”
moderate“There was a chaotic atmosphere during the inspection...Files we asked for were in locked cupboards where the staff member had left the building with the key.”
incident learning
3 findings
moderate“The registered manager had also failed to notify us of a Police incident earlier in the year as required.”
moderate“Accident and incident reports did not always include a full description of the incident or identity the necessary actions needed to reduce risk of reoccurrence.”
moderate“incidents were not considered for possible learning or improvements.”
missed or late visits
2 findings
moderate“Six people and relatives spoken with said that their calls were late particularly at weekends and of these 3 said they were not contacted by the office or by care workers.”
moderate“poor oversight of the call monitoring system which meant that late or missed calls may not be identified...One staff member had a punctuality rate of 28 per cent.”
staff training
2 findings
moderate“New in post care coordinators were completing assessments of people's care. However, there was no record that they had received any relevant training in this area.”
moderate“Records did not demonstrate staff had all received the training they needed to perform their role...some staff had provided support prior to their work shadowing.”
staff competency
1 finding
critical“For 4 members of staff we found full recruitment checks had not been carried out in line with the regulations. This included new DBS checks, references and gaps in employment history.”
person centred care
1 finding
moderate“Staff did not always have guidance on how to provide person centred care. Care plans did not always guide staff on people's individual preferences, likes and dislikes.”
cultural competency
1 finding
moderate“Care plan records did not show how people's needs under the Equality Act, such as their culture, religion or sexuality had been discussed or considered.”
consent capacity
1 finding
minor“For 2 people best interest meetings, particularly in relation to consent to care or medicine management were not always clearly recorded to evidence the assessment of each separate decision.”
supervision appraisal
1 finding
moderate“For another 2 staff members there was no record to evidence they had completed their induction training.”
complaints handling
1 finding
minor“feedback from people and their relatives suggested they had raised complaints informally which while resolved were not recorded on the complaints tracker to identify learning.”
staffing levels
1 finding
minor“an additional driver would reduce the number of late calls in the Surrey area due to traffic...no evidence these issues had been considered by the provider.”