critical“one person had regularly been given paracetamol more often than the recommended four hourly timeframe. This meant they were being overdosed and at risk of significant harm.”
critical“Time critical medicines were not always being given consistently as recommended. For example, one person who received a medicine associated with Parkinson's disease was given it on different days at 13.45, 11.50, 12.10 and 13.15.”
critical“The records did not always clearly show the person's prescribed medicines and instructions for their use. One record showed a list of the person's medicines but there was no detail about the dosage or how often they were to be taken.”
critical“There were gaps in recording on some of the MARs. This meant there was no evidence to show if people had been administered their medicines, as prescribed.”
moderate
“At our last inspection, medicines were not managed safely. At this inspection improvements had been made to the administration, recording and auditing of medicines.”
critical“medicine administration records stated the medicines were given at 11.05 and again at 11.50. Assessments to identify any risks with medicines, had not been completed.”
missed or late visits
5 findings
critical“Timings of visits were inconsistent, and not always at a time to suit the person... one person who needed their teatime visit at 18.00, due to dietary needs, but some of their visits were documented as 19.00, 18.55, 20.15 and 19.20.”
moderate“I feel it is an utter shambles to be honest. This morning they came at 11:45am but we asked for a carer between 7:00am - 7:30am.”
moderate“The majority of people told us the office did not tell them if staff were going to be late.”
minor“Sometimes they don't get here till 11:30...they can be a bit late but nothing excessive, though they don't always stay the full time.”
moderate“staff arrived to support one person at varying times between 07.07 and 10.58. Their preferred time was between 09.00 and 09.45.”
record keeping
4 findings
moderate“The medicine administration records (MAR) were not always clear and did not always detail all medicines, and their prescribing instructions. The MARs had not always been fully completed by staff”
moderate“A person had fallen and sustained injuries. Staff had not documented how the person presented, their pain or any adjustments they needed with their care.”
minor“Much of the information within the log was task orientated and did not demonstrate areas such as how the person presented.”
moderate“visits were recorded as cancelled rather than missed. This did not give an accurate account of the missed calls, which had occurred.”
governance
4 findings
critical“the auditing systems in place were not sufficiently robust in identifying and addressing shortfalls in the service. This was a breach of Regulation 17, Good governance”
moderate“The issues leading to people's dissatisfaction, as raised during the inspection, had not been identified or further explored. This did not ensure improvements were made.”
moderate“Audits were not effective as shortfalls in the service were not always being identified or addressed. Recommendations made at the previous inspection had not been fully addressed.”
critical“Audits were not effective as shortfalls were not always being identified or addressed. Recommendations made at the last inspection had not been fully addressed.”
care planning
3 findings
moderate“The content of people's care plans was variable in detail and accuracy. For example, one care plan stated a person had a catheter, but there was nothing about the management of the catheter”
moderate“At our last inspection in June 2019 care plans did not reflect people's preferences of times of visits. People did not always receive visits at the times they were expecting.”
moderate“information was not always transferred to people's support plans. This included aspects such as self-harm, and the restrictions associated with arthritis.”
person centred care
3 findings
moderate“Much of the information about people's support, which staff documented in the communication logs, was task orientated and not person-centred.”
moderate“People's wishes in relation to who supported them were not always respected. Some people cancelled their visits as the allocated staff member was of a different gender, to what they wanted.”
moderate“one person's support plan stated they liked to 'get up late morning' but some of their visits were around 08.30.”
complaints handling
3 findings
minor“Improvements had been made to the complaints process following a complaint which had been made before our inspection and not been handled well.”
minor“Some entries on the daily handover forms, which could be seen as complaints or concerns, were not documented separately on the complaint's log. This did not enable the information to be captured and potential trends to be identified.”
minor“some people said they were not sure how to make a formal complaint. Most were not upheld with the outcome being 'customer perception.'”
staff competency
2 findings
moderate“not all staff had completed an assessment to demonstrate their competency when managing people's medicines.”
moderate“If the regular carer is on holiday, they send in staff that haven't even used the hoist. They can't even operate it.”
staffing levels
2 findings
critical“There were not always enough staff to ensure the reliability and efficiency of the service. This was particularly so at weekends or at times of staff sickness.”
critical“One relative told us their family member required two staff to assist them at each visit but there were occasions when only one member of staff attended.”
staff training
2 findings
moderate“Records did not show staff had received training around people's complex medical conditions. This included Multiple Sclerosis and PCP (Progressive Supranuclear Palsy).”
moderate“staff provided personal care to some people with mental health conditions but had not received specific training in such areas.”
incident learning
1 finding
moderate“There had been regular errors with people's medicines and as a result, the staff involved had received additional training. However, there was no investigation as to why the errors were occurring.”
infection control
1 finding
moderate“the testing was not mandatory, and staff were not required to inform the registered manager of the test's completion or the results.”
consent capacity
1 finding
critical“One person's plan stated they were to be given their medicine on a spoon with meals or yogurt. It was not clear whether this was to covertly administer the medicines or to aid swallowing with the person's consent.”
end of life care
1 finding
minor“One support plan did not clearly show the care the person needed, as their health deteriorated.”