critical“quality assurance and monitoring systems were not fully embedded and were not fully effective at addressing the shortfalls we identified on inspection.”
moderate“provider's audits had not identified the concerns we found in relation to medicines and recruitment.”
critical“A structured quality monitoring system was not in place and all shortfalls had not been identified prior to our visit.”
record keeping
3 findings
critical“People's medicines records were not always accurate, complete and contemporaneous. While this placed people at risk of harm.”
moderate
“we have found several gaps in the recording of the daily notes for one person.”
moderate“The provider did not ensure records were kept of all care people received.”
medication management
2 findings
critical“"As required" time sensitive medicines, such as pain relief, were not always administered with the required minimum time gap in between administration.”
moderate“There were gaps in the recording of people's medicines or medicines were recorded as having been administered late.”
staff competency
2 findings
critical“Safe procedures were not followed when new staff were recruited to ensure they were safe to provide care to people.”
critical“Safe procedures were not followed when new staff were recruited to ensure they were safe to provide care to people.”
communication with families
2 findings
minor“Can't say I hear from the office and I haven't had any requests for feedback about the company or the care.”
moderate“The provider did not collect feedback from people who used the service and their relatives. This meant that people's views were not sought to evaluate and improve the service.”
care planning
1 finding
critical“Risks to people had not always been assessed or planned to ensure they received care safely.”
staff training
1 finding
critical“Staff were supporting people with testing their blood sugar levels but had not received training from a competent health care professional to ensure they could undertake this task safely”
missed or late visits
1 finding
critical“the provider had not explored the impact of these missed care visits on people's safety to determine whether additional risk management plans needed to be put in place”
infection control
1 finding
critical“Regular Covid-19 staff testing was not being completed in line with current government guidance. The provider was unaware of the regularity of staff testing.”
safeguarding
1 finding
moderate“The provider had not always scrutinised all late or missed care visits to ensure people remained safe... to ascertain if a safeguarding referral to the local authority is required.”
complaints handling
1 finding
moderate“Records of complaints received from people were not kept to show how the service had responded to people's complaints.”
incident learning
1 finding
moderate“the service did not have an improvement plan in place to evidence actions taken to improve the quality of the service.”
leadership
1 finding
moderate“it was evident that the staff relied heavily on the registered manager for day to day support. The registered manager talked to us about the time constraints and volume of work in their job role.”