critical“Where people were being supported by staff to receive their medicines there was not always a medicine administration chart (MAR) and accompanying risk assessment in place.”
moderate“Audits of medication records lacked detail of any actions taken for example to explain gaps in recording, excessive use of PRN or if time specific medicines were administered.”
moderate“one person's care records contained conflicting information as to whether the person was being prompted or assisted to take their medicine.”
missed or late visits
3 findings
moderate“Sometimes staff are late which means my medicines can be late, there may only be an hour gap between the morning and lunch call because the morning call is so late.”
moderate
“The time between calls can be over 14 hours especially if there has been an early evening call then a late morning call, the next day.”
moderate“twice we had calls so late they were positively a nuisance.”
care planning
2 findings
critical“Health needs people may need support with, such as diabetes had no supporting documentation, care plans or risk assessments for staff to follow.”
moderate“Care records lacked detailed information and/or guidance for staff to follow to mitigate individual risks to people.”
record keeping
2 findings
critical“Care documentation did not contain all the details staff needed to support people safely. This placed people at risk of receiving unsafe care and support.”
moderate“Another person had a catheter, but no care plan or risk assessment was in place to identify the risks associated with their catheter care.”
governance
2 findings
critical“There had not been robust governance systems in place at the service over the previous 12 months.”
critical“There was a lack of robust quality assurance meaning people were at potential risk of receiving poor quality care.”
staff competency
2 findings
moderate“Staff training had not always been consistently completed or their competency checked.”
moderate“Staff had received training in the administration of medicines, but no on-going competency checks had been completed.”
supervision appraisal
1 finding
moderate“We found limited evidence of staff supervision, or spot checks being completed consistently, and staff did not have an induction to the service recorded.”
staff training
1 finding
moderate“One member of staff told us they had not received practical moving and handling training until a few months after they commenced work.”
person centred care
1 finding
moderate“Care had not been planned in a person-centred way, with people being given 2-hour call windows of when they may receive care.”
communication with families
1 finding
minor“People told us they did not know which carer would be coming to provide care as they were not given any rota or timings for care calls.”
incident learning
1 finding
critical“two safeguards had been raised against the service. The provider had failed to submit the relevant notifications to CQC.”