critical“we saw a number of unexplained gaps on the MAR for one person and the MAR for another person did not record the maximum dose staff could administer.”
critical“We looked at the medicine records for eleven people who used the service. We found the records did not provide a clear and accurate record of the medicines staff had administered to people.”
critical“On 19 June 2016 an entry read 'Unable to give night time medicines as none been delivered again'. We saw no evidence the person received their medicines until lunchtime, 21 June 2016.”
critical“The entries did not detail the strength of the medicine, the dose of medicine staff were to administer or how the medicine should be administered.”
staff training
4 findings
minor
“staff also completed a practical session in moving and handling people, however, we could not find documented evidence of this in the staff files we reviewed.”
moderate“Of the 110 staff listed, 14 staff had not refreshed their [safeguarding] training within this timeframe, six of whom had gone over two and half years.”
moderate“16 staff had not refreshed their moving and handling training within the annual timescale...five staff had gone over eighteen months since they last completed the training.”
critical“22 of the 65 staff had not updated their moving and handling training for over fourteen months...eight staff had not completed any training in first aid.”
missed or late visits
3 findings
moderate“52% of people who responded said care staff were late. The survey was audited and an action plan was created which considered time management, communication and continuity.”
minor“Their timing leaves a lot to be desired, they quite often turn up late and [person] has struggled into their clothes by then.”
moderate“From January to August 2015 the percentage of people who received their call within the time frame allocated by the local authority ranged between 75% and 78%.”
record keeping
3 findings
critical“two service user handling plans dated 14 September 2016...recorded conflicting information; one instructed staff to use a handling belt and the other instructed staff to use a hoist and sling.”
moderate“Daily logs had only been returned for each month, between April and June for one person. None had been returned for another person.”
critical“One person had commenced using the service in March 2015 but there were no daily records available after July 2015.”
consent capacity
3 findings
critical“people's records did not evidence compliance with the Mental Capacity Act 2005.”
critical“Where people were living with dementia, there was no evidence of either mental capacity assessments or best interest's decision making.”
moderate“Only 19 of the 65 staff listed had completed training in the Mental Capacity Act 2005.”
supervision appraisal
3 findings
moderate“four staff had not received a field based observation of their practice in the last seven months.”
moderate“I think I have only had one [supervision] this year. Some girls have said they have asked for one but they haven't had one.”
moderate“One said they thought their last supervision was eighteen months ago and another said their last supervision was at the beginning of 2015.”
governance
3 findings
moderate“audits of people's daily records did not check that the content was reflective of the care plan.”
critical“The registered manager said 'There is a report and an action plan has been done, we are in the process of working through it.' When we asked to see the action plan the registered manager told us, 'No there isn't one.'”
critical“The audits which had been completed had not picked up on the issues we found during our inspection.”
care planning
3 findings
moderate“the manager acknowledged the audit had not checked to ensure the content of care plans was an accurate description of people's needs.”
critical“We found a document entitled 'personal plan' dated 12 January 2005...the person received care each morning and required the use of a hoist for all transfers.”
critical“One care plan had been reviewed in September 2014 and another in June 2013 but there was no evidence they had been reviewed since.”
complaints handling
3 findings
moderate“a person who had raised a complaint in July 2016...at this inspection we saw from the complaints log the matter had still not been addressed.”
moderate“We noted two incidents where people had said they were unhappy with the service but the matter had not been addressed as part of the complaints process.”
moderate“One person told us they had raised two complaints but these were not logged in the complaints file.”
staffing levels
2 findings
moderate“Staff work 11 hours without breaks on occasion and nothing is done. Rotas were given in advance but sometimes only by a day and there was not always sufficient travel time between calls.”
moderate“only one member of staff had attended their call instead of two 'on several occasions'...due to staff shortages people were not consistently receiving their full package of care.”
staff competency
2 findings
critical“Only two of the staff we spoke with said their competency had been assessed by a more senior staff member.”
critical“We were unable to evidence staff were competent to administer peoples medicines and the system for recording the administration of medicine was not robust.”
person centred care
1 finding
minor“Some people had inconsistent call times and the registered manager agreed to look at these in more detail to see if there was any scope to promote greater consistency.”
communication with families
1 finding
minor“Another relative said it was difficult not knowing what time care staff would arrive as they did not have a rota in advance.”
safeguarding
1 finding
critical“A relative told us they had reported a safeguarding incident to the registered manager earlier in the year...the social worker was unable to find any record of the matter on their database.”
leadership
1 finding
critical“At the time of this inspection there was a lack of evidence to support either the registered provider or the registered manager having oversight of the service as a whole.”
incident learning
1 finding
critical“During our inspection we found evidence regulatory breaches identified at our inspection on 12 November 2015 had not been addressed.”