critical“We found two peoples care records did not contain a medication administration record (MAR) or body maps to guide staff where to apply their prescribed creams.”
critical“A staff member was helping another person's relative administer their medication without a MAR chart in place.”
moderate“There were no audits of people's medication charts. This meant potential medication errors could not be highlighted and learned from.”
moderate“staff had signed for medicines the person told staff they had taken prior to their visit. This person was living with dementia and experienced periods of confusion.”
governance
4 findings
moderate
“the provider had failed to identify two people were receiving staff support with their medicines without a MAR chart.”
minor“the action taken in response to any negative feedback was not always clearly recorded.”
critical“Any audits implemented were ineffective in identifying the concerns we highlighted about safety, people's experience of care and the governance of the service.”
critical“the provider had failed to continuously and effectively monitor the quality of the service since they registered with us as they had not completed audits on any aspects of the service.”
record keeping
3 findings
moderate“we did identify unexplored gaps in staff members' employment history”
moderate“One person's care plan recorded a number of time sensitive medications they needed carers to administer. However, the person's daily records did not detail whether support with medication was taking place and MAR were unavailable.”
moderate“training records had not been completed... The provider was unable to clarify whether this staff member had received training with a previous employer as their records were not complete.”
person centred care
3 findings
moderate“People's preferences in relation to their care calls times were not met, and they had experienced late and, sometimes, missed calls. This did not reflect a caring approach.”
moderate“People consistently told us they had not been involved in reviews of their care. Some people told us concerns about the outcome should they express their views.”
moderate“prior to the manager starting people did not consistently have regular reviews of their care.”
missed or late visits
2 findings
moderate“most of the relatives we spoke to told us their family members continued to experience late calls and some relatives told us their family members occasionally experienced missed calls.”
critical“The morning call was 90 minutes late which meant the person had recently had breakfast when carers then arrived to support with lunchtime.”
care planning
2 findings
moderate“some people's care records required clearer information for staff to follow to support people with specific health conditions, such as diabetes.”
moderate“Plans were not always reviewed in line with the provider's own policy. For example, the risk assessment for a person at high risk of pressure areas had not been reviewed regularly.”
communication with families
2 findings
minor“Two people's relatives felt their concerns about their family members' care had not always been responded to appropriately.”
moderate“Feedback from people and relatives informed us that communication with the service was inconsistent. Some people were not updated about changes to their care calls or informed about delays.”
staffing levels
2 findings
critical“Feedback from people and relatives consistently reported incidents of care calls being late, missed or a single carer attending when two staff were required to meet the person's needs.”
critical“one staff member had been working at the service without a Disclosure and Barring Service (DBS) check... three staff members had been working without valid references.”
staff training
2 findings
moderate“Training records showed that only half of staff were up to date with Infection Prevention Control training.”
critical“one staff member had been working without any training... staff supported a person with epilepsy however had not received training in this area.”
supervision appraisal
2 findings
moderate“Staff competency in areas such as medication management, moving and handling or infection control was not regularly monitored.”
moderate“Quality assurance checks on medicines had not identified where staff had signed for medicines they had not administered and therefore where staff's competency required assessing.”
staff competency
1 finding
critical“Staff records did not detail the specific equipment that individual staff were trained to use... regular staff competencies in moving and handling techniques were not yet completed.”
infection control
1 finding
critical“Carers wore the same gloves for all tasks, including after carrying out personal care or applying creams... staff wore the same apron for personal care and food preparation.”
safeguarding
1 finding
critical“We were informed of incidents of potential abuse that were not raised with the safeguarding team.”
incident learning
1 finding
critical“A person who required two carers to receive personal care safely had been supported by a single staff member. The manager had been aware of this incident, but no further action had been taken.”
complaints handling
1 finding
moderate“The system in place to monitor feedback and complaints from people was not robust. The process in place was not consistently followed or reviewed in line with the provider's own timescales.”
leadership
1 finding
moderate“There has been no registered manager in post since February 2021.”