critical“A full employment history was not sought for all newly employed members of staff. Two written references were not received for three members of staff prior to commencing in post.”
moderate“Staff had received medication training but had not had their competency assessed through direct observation to ensure their practice was safe.”
critical“Staff had received medication training but had not been assessed as competent before being involved in the administration of medicines.”
critical“Not all staff were comfortable and felt able to competently support this person effectively. Online training relating to this person's medical condition was only provided to staff following our enquiry.”
governance
3 findings
critical
“Governance arrangements were not robust and effectively managed. This placed people at risk of harm. A Warning Notice was served”
critical“The manager was not registered with the Care Quality Commission. The manager confirmed an application to register with us had been forwarded but upon checking our records this had not been received.”
critical“Effective governance and quality assurance arrangements were not in place to assess, monitor and improve the quality and safety of the service provided.”
medication management
3 findings
moderate“'No outcome' was recorded, giving no indication if the person had received their medicines or not. Medication audits were not being undertaken.”
critical“The MAR for three people showed there were numerous gaps on the MAR form. There was nothing to demonstrate if the person's medication had been administered or omitted.”
critical“The MAR form for one person in May 2019, showed they did not receive all of their prescribed medication in line with the prescriber's instructions. This referred specifically to an antibiotic medication.”
communication with families
3 findings
moderate“If you try to contact [Naidcare] I wouldn't be able to, based on previous attempts as there is no voicemail, it just rings.”
minor“some relatives expressed concern that not all telephone calls were returned or returned in a timely manner.”
moderate“There was a lack of evidence to demonstrate how the service assessed people who had a disability, impairment or sensory loss to receive information they can access and understand.”
record keeping
3 findings
minor“A written record was not completed or retained for two members of staff to demonstrate the discussion taken place as part of the interview process.”
moderate“gaps in employment not explored for one member of staff, no evidence of an Adult First Check for one member of staff and no evidence of interview records for two staff members.”
moderate“A record of the assessment had not been maintained by the field supervisor.”
staff training
3 findings
moderate“A member of staff had commenced the 'Care Certificate' but this had not been completed despite having been employed since June 2020 and having had no previous experience in a care setting.”
critical“Not all staff had evidence of up-to-date medication training. Staff's competency to administer medication was not assessed.”
moderate“No information available to demonstrate the registered manager or the other trainer had attained a 'train-the-trainer' qualification.”
supervision appraisal
2 findings
moderate“Robust induction arrangements were not in place for all staff. Not all staff had received regular supervision or spot check visits.”
minor“Where negative comments were made, these consistently related to staff not wearing their uniform or identification badge. No information was recorded detailing how these issues were to be monitored and addressed.”
incident learning
2 findings
moderate“142 calls recorded staff were logged in at two locations at the same time and 351 had no staff travel time included. This had not been picked up by the provider or registered manager.”
moderate“Suitable arrangements were not in place to evaluate and review people's MAR forms to enable lessons to be learned.”
care planning
2 findings
moderate“further information was required to demonstrate how risks to a person's wellbeing and safety were to be mitigated and to ensure these were individualised, person-centred and not generic.”
critical“Two out of five care files viewed did not have a support plan in place detailing all aspects of a person's individual circumstances and needs.”
leadership
2 findings
moderate“the manager was unaware of the improvements still required relating to recruitment, ensuring staff had completed medication competency assessments and that the completion of the Care Certificate remained incomplete.”
moderate“Not all staff in key positions understood their roles and responsibilities. There was no documented evidence to demonstrate the improvements required and how their performance was to be effectively managed.”
person centred care
2 findings
minor“when an unfamiliar staff member was required to provide support due to staff annual leave or sickness, neither the person using the service or their relative was forewarned in advance.”
moderate“People's comments suggested staff primarily focused on tasks rather than the people themselves. People told us they wanted staff to spend time with them, sit and talk, but this rarely happened.”
staffing levels
1 finding
critical“195 calls out of 1126 for June and August 2022 were more than 45 minutes late. There were 48 calls which were not logged despite the provider having an automated system”
safeguarding
1 finding
critical“Internal investigations were not commenced or completed in response to the allegation of harm to ensure lessons were learned and improvements made when things go wrong.”
missed or late visits
1 finding
moderate“People told us there had been many occasions where staff were late. One person told us, 'If staff run late, it is usually about 15 to 20 minutes. There are odd occasions when it has been beyond 30 minutes.'”
consent capacity
1 finding
minor“Improvements were required to ensure people's capacity to make decisions was clearly recorded.”