moderate“three people who were prescribed anticoagulants. These people's care plans did not have guidance for staff to help staff monitor and manage the side effects of these medicines.”
minor“We found that not all senior staff were up to date with their auditing of medicines. We discussed this with the senior management team who assured us this would be addressed.”
critical“there were discrepancies in information recorded in all 10 cases...the agency did not have formal procedures and policies on transferring information about people's medicines”
critical“it was not always clear if a person self-medicated or if administration was shared between the agency's staff and a person's family”
missed or late visits
3 findings
moderate
“Six out of seven people...reported frequent staff changes, poor staff punctuality, and shorter visits than planned. Four people said there were some occasions when staff did not turn up at all.”
minor“between August and November 2018 there were on average 11 low risk missed calls a month because the agency did not manage to secure a replacement staff at the short notice.”
minor“Two people reported that they had recently experienced a missed care visit...issues around time keeping during weekends and when their regular care staff were absent”
care planning
3 findings
minor“some care plans needed more information on specific aspects of care for individual people...some risk assessments needed more personalisation to reflect specific risks for specific individuals.”
minor“Some care plans would benefit from more detailed information on people's background and how exactly they would like to receive support.”
moderate“for a person with epilepsy...there was no direction or advice on how to manage or respond to a seizure if necessary”
record keeping
3 findings
moderate“Some staff were not logging in and out of their visits, making it difficult for us to ascertain if calls took place.”
minor“monitoring systems around staff training mostly included manual checks and cross-referencing of staff training records. This was time consuming and could cause monitoring errors.”
moderate“medicine audits for one person for July and August 2017 had not identified that MAR charts did not have recorded medicines details, known allergies and other information”
consent capacity
2 findings
minor“one person had consent given by their next of kin without evidence to support that this had been appropriate and in their best interests.”
moderate“there were not always clear records stating if those family members who were making decisions on their behalf had a Lasting Power of Attorney”
supervision appraisal
1 finding
moderate“We saw in staff files that these activities had not always been recorded to show that they had taken place and what was discussed/agreed.”
communication with families
1 finding
minor“Some people using the service and their families raised concerns around communication about staff lateness and changes to staff.”
governance
1 finding
moderate“there were no overall managerial auditing systems and procedures...the agency did not have effective tools to monitor and assess the quality of the care”