critical“Two people had a diagnosis of epilepsy. Their epilepsy action plans guided staff to contact 111 in the event of a seizure...the manager confirmed neither of these instructions were accurate.”
moderate“Improvements were needed to ensure people's assessments were reviewed following changes in their health, to ensure they remained relevant and up to date.”
critical“One person with epilepsy had no risk assessment or care plan for their condition until after they had experienced seizures.”
critical“One person's assessment indicated they had epilepsy, but there was no information about this in their care plan or risk assessments.”
governance
4 findings
critical
“Audits and governance processes of the safety and quality of care were either not in place or operating effectively.”
critical“Systems to continually assess, monitor and mitigate risks to the health, safety and welfare of people...were ineffective. This placed people at risk of harm.”
minor“no other audits had been carried out to review the service's performance because the provider had only recently secured a care package.”
critical“The Provider had failed to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.”
record keeping
4 findings
moderate“Records relating to staff employed were not always stored securely. Spot checks of staff practice and their competency were kept in people's homes and not the registered office location.”
moderate“There were no records available to evidence the training staff had undertaken or observations of their practice.”
minor“the provider had not obtained a full work history for one care worker which meant we could be clear as to the source of the reference on the file. The provider assured us the checks had been made, but not recorded.”
critical“The provider was unable to evidence that reference checks and employment history for new staff had been obtained prior to employment.”
staff training
3 findings
minor“Staff weren't attending training even though we would book it, and there were gaps in staff training records.”
moderate“The provider told us staff received medicine competency training before being allowed to support people with their medicines. However, there were no records of training.”
moderate“There was no organised system to ensure staff had the training to administer medicines safely.”
medication management
2 findings
critical“Medicine administration records (MARs) were not always clear and did not always follow best practice guidance. There were unexplained gaps and crossings out in records.”
critical“One person needed support with epilepsy medicine because of short term memory loss. However, due to a lack of understanding there was no medicine administration record for this person.”
staff competency
2 findings
moderate“The manager advised us that spot checks of staff competencies to administer people's medicines were carried out. However, there were no records of these checks.”
moderate“The provider had not ensured all staff had received training relevant to their roles.”
leadership
2 findings
moderate“At the time of the inspection, there was no registered manager in post.”
moderate“The registered manager was unavailable throughout the inspection process and was not responsive to requests made by the inspector.”
consent capacity
1 finding
moderate“Improvements were needed to ensure statements regarding people's mental capacity were supported by mental capacity assessments.”
safeguarding
1 finding
minor“Contact details for the safeguarding authority were available for staff in the office, but not all staff knew where to access this information or who to contact externally.”
incident learning
1 finding
moderate“Care records did not always evidence when action was taken in response to health concerns or incidents or when conversations took place with other health professionals.”
supervision appraisal
1 finding
moderate“There was no system to identify what training staff had attended and when refresher training was required.”