critical“One person was prescribed heart medicine to be given twice daily. A MAR chart showed this person was only administered this medicine once daily, over the course of a month.”
critical“MAR charts did not always include dosage or special instructions, to ensure staff had the information they needed to provide people with the right medicine at the right times.”
care planning
2 findings
critical“One person was at high risk of skin breakdown and had wounds which were treated by district nurses. However, their care plan lacked guidance for staff on managing the risk.”
critical“There were no risk assessments for catheters, and care plans lacked clear instructions for staff on their responsibilities relating to catheters.”
governance
2 findings
critical“Audits and governance processes to maintain oversight of the safety and quality of care were not operating effectively. This put people at increased risk of not receiving safe, quality care.”
critical“Important events and incidents were not notified to CQC as per regulatory requirements. In response to our feedback, notifications were submitted.”
record keeping
1 finding
moderate“Quality assurance checks were not always recorded or available to view during the inspection. The manager told us that medicine competency observations were carried out, but there were no records.”
consent capacity
1 finding
moderate“Two people's care records included a statement of capacity confirming they lacked capacity, which the registered manager advised us was incorrect.”
complaints handling
1 finding
moderate“The provider had a complaints policy. However, records to demonstrate how complaints were responded to, as per the provider's policy, were not available.”
missed or late visits
1 finding
moderate“Some people told us their call times were suitable, other people said they were too early or late. People did not always know which care staff were coming.”
staff competency
1 finding
critical“One relative said, 'One carer pulled out my relative's catheter and my relative ended up in hospital.'”
safeguarding
1 finding
critical“When safeguarding concerns were raised, the registered manager took action to investigate those concerns and refer them to the local authority. However, CQC were not always notified.”