moderate“Where people were prescribed PRN medicines, guidance was in place but there was no information recorded about the effectiveness of the medicine following administration.”
minor“There were no risk assessments in place for prescribed creams stored in people's bedrooms.”
critical“Staff trained to administer medicines were not available through night-time hours. Meaning, people who may need 'as required' medicines could not be provided with them if required.”
critical“Medicines were not stored at the correct temperature and some medicines belonging to people were found to be stored in different areas of the service.”
critical“Two records of CD drugs did not tally with the drugs stored... Medication audits were not robust or effective as discrepancies had not been identified.”
incident learning
4 findings
moderate“Behaviour charts were used as a record of an incident but they were not written in a way which identified what happened before, during and after the behaviour so learning could be identified.”
moderate“It was not evidenced that all incidents were reviewed by the provider, meaning lessons were not learned from these.”
moderate“Accidents and incidents had still not been appropriately reviewed. The registered manager reviewed incidents of falls, however had not reviewed other incidents.”
moderate“Analysis of accidents and incidents did not include all accidents that had happened so could not fully identify any patterns or trends to help mitigate risk and prevent reoccurrence.”
governance
4 findings
moderate“Medicines audits were undertaken but improvement was needed to ensure PRN protocols and risk assessments were reviewed.”
critical“Audits were not always effective in identifying concerns. For example, daily walk around checks and audits had not identified concerns found in relation to infection control, fire safety, environmental risks, and medicines.”
critical“Effective governance systems were not in place to ensure the quality and safety of the service. There was a lack of overarching governance from the provider.”
critical“Governance systems were in place but not always effective. The registered manager's quality audits for medication, risks, infection prevention and control were not effective”
infection control
4 findings
minor“There were shortfalls around cleaning of the laundry area and freezers. The outside bins were overflowing as a result of their position and organisation of the bin area.”
moderate“The kitchen remained visibly dirty. Food items did not contain dates of defrosting, meaning several food items appeared to be out of date. Kitchen audits had not identified concerns.”
critical“Some areas of the home were visibly dirty and effective cleaning schedules were not implemented. We found faeces on a light pull switch.”
moderate“the cook was dressed in their outdoor clothing and did not always change the plastic apron when they returned to the kitchen from taking a break outside.”
safeguarding
3 findings
minor“Safeguarding records were maintained and organised. The information in the records would benefit from analysis to identify causative factors or precursors which would identify learning.”
critical“A recent incident relating to a fall had not been reported to CQC or the local authority, as required. Another incident relating to missed care calls, had not been reported to CQC.”
critical“We found 3 incidents which were not reported to the CQC or the local authority as required. This meant people were not always protected from the risk of abuse.”
care planning
3 findings
critical“1 person's records did not contain detail about how to safely support them during incidents of emotional distress, how to provide pressure care or how bed rails should be used safely.”
critical“Care plans did not contain enough detail to guide staff on how to provide individualised care. Some contained conflicting information about another person.”
critical“Risks to people's safety had not always been assessed and recorded. For example, one person who smoked created a potential risk to themselves and others. However, there was no risk assessment in place for this.”
record keeping
3 findings
moderate“The provider and registered manager failed to appropriately audit records. For example, gaps found in kitchen and cleaning records were not identified.”
moderate“Peoples records were not confidentially stored. We found various records containing sensitive information stored in a communal area.”
moderate“We found records of pressure care for people were not up to date. On the day of the inspection staff had not completed the two hourly turn charts for people since the day before.”
missed or late visits
2 findings
moderate“People receiving support from the domiciliary care service were not always provided with staff for their allocated call times, in line with their assessed needs.”
moderate“People using the DCA service said often staff did not arrive at the agreed time.”
staff training
2 findings
moderate“Catheter care and nutritional training was not undertaken.”
moderate“Some staff had not received training in pressure area care. Staff had not completed catheter care or nutritional training, which was required to safely support people.”
complaints handling
2 findings
moderate“Records were not in place to evidence any action had been taken to investigate or address this complaint.”
minor“Initially when I raise concerns it goes back to being good, but then goes back to the same.”
consent capacity
2 findings
minor“Consent for CCTV in communal areas of the home, had not been sought.”
moderate“The service had CCTV systems in place in the communal areas of the home and people had not consented to this.”
leadership
2 findings
critical“There was a lack of leadership in the service and the providers governance systems were not effective in improving the quality and safety of the service.”
moderate“The registered manager had recently provided care calls to people in the community due to staffing issues, which meant resources were not in place for management and oversight.”
staffing levels
2 findings
critical“We could not be assured enough staff were provided to keep people safe. Where people received care at home, one relative told us, 'Staff are routinely late, there is an issue with staffing.'”
critical“We were not assured there were enough staff deployed to keep people safe. The provider did not use a dependency tool to ensure there was a safe number of staff”
person centred care
2 findings
moderate“People were not always provided with call alarms to enable them to request support when needed. Care plans did not contain enough detail to guide staff.”
moderate“We saw people living in the care home were left unsupervised whilst eating and for considerable periods throughout the day.”
supervision appraisal
1 finding
minor“Whilst some staff supervisions were in place, improvement was required to bring these up to date.”