critical“when a fall had occurred, people's care plans and risk assessments were not always updated to reflect the circumstances of the fall and any impact on how care was provided.”
moderate“The care plan had not been reviewed since September 2020 and still included care activities which either had not been provided or were no longer required.”
governance
2 findings
critical“audits of both these documents had not identified the discrepancy between the information...checks carried out were not robust enough to indicate where actions were required.”
critical“The provider did not have robust audits and quality assurance processes to enable them to assess and identify where action was required.”
incident learning
2 findings
moderate“incident and accident record identified this person should not be left on their own...but this was not achievable as the staff member was not able to supervise the person all the time. There were no other actions identified.”
moderate“There was no information on how incidents and accidents relating to people using the service should be recorded, investigated and any lessons learned identified.”
record keeping
2 findings
moderate“a staff member had completed the MAR indicating they had administered the medicines at a specific time. A different staff member had completed the records of care stating they had given these medicines.”
moderate“The number of visits per day increased. The care plan had not been updated to show this and provide information for care workers on what support the person required.”
medication management
1 finding
critical“staff member had administered an over-the-counter medicines which had not been prescribed and was not identified in the care plan. The possible interactions this medicine could have with the prescribed medicines had not been identified.”
staffing levels
1 finding
critical“The provider did not always follow their recruitment procedures to ensure appropriate checks had been carried out on applicants to ensure they were suitable for the care worker role.”
staff training
1 finding
critical“The provider confirmed they had not completed any training. Both care workers had been in post since July 2020.”
supervision appraisal
1 finding
moderate“There were no records of any supervision or appraisals being carried out for all three care workers.”
safeguarding
1 finding
moderate“The provider had not developed COVID-19 risk assessments or risk management plans for people receiving care or for care workers.”
leadership
1 finding
critical“The registered manager had not been actively involved with the service for around five months.”