minor“on some occasions staff had forgotten to complete the duplicate electronic medicine administration record.”
minor“due to the pandemic, there had been a few occasions when there had been a delay in updating a change in care in the plan located in people's homes.”
minor“Some MARs we looked at had a few staff signature gaps and these had been investigated by the registered manager.”
moderate“The provider only had records that ran from 1 May 2018 to 1 June 2018. When we asked for records pre-dating this, we were told these were not available because they did not have them.”
moderate“care plans had not always been updated to reflect people's needs... person no longer had a catheter. The person's care plan had not been updated.”
moderate
“Whilst medicine administration records were checked, and individual actions taken when needed, there was no overall analysis audit record. This meant themes where improvement were not collated to form an action plan.”
missed or late visits
4 findings
moderate“during July and August 2018, the provider's records showed there had been 13 missed care calls.”
critical“My morning call is meant to be 08.30 – 09.30, but they arrived at 13.30. I should then have a call between 16.30 and 18.30, but they came at midnight.”
critical“I had to crawl to the toilet and sat in my own urine for twenty minutes”
minor“There had been a small number of missed or late care calls because of human error. For example, a staff member had miss-read their rota.”
governance
4 findings
moderate“Further improvements to the provider's call monitoring system was due to be implemented in October 2018...We were therefore unable to assess the effectiveness of this during this inspection.”
critical“Regulation 17 HSCA RA Regulations 2014 Good governance — Warning Notice issued. Provider did not always assess, monitor, improve the quality and safety of the services.”
critical“Most MAR sheets had not been returned to the office for auditing since May 2017”
moderate“audits of people's care logs did not always identify where improvement was needed. We saw a staff member had recorded safety concerns about one person and whilst actions had been taken, these had not been recorded”
care planning
4 findings
moderate“one relative told us their family member's care plan was '75% incorrect'... stated their family member lived with dementia, when in fact they had a totally different health condition.”
moderate“person now needed to be cared for in bed due to deterioration in their health... care plan recorded, 'I would like to be left in my armchair'”
minor“information in people's care plans had not always been updated. The registered manager was aware of this and showed us the work they had been doing to update all care records.”
minor“some had not been fully completed, and included little information on people's life history, for example.”
supervision appraisal
3 findings
minor“Staff told us their individual meetings were 'a bit behind' but recognised other support systems were in place.”
minor“records of communication were not always kept, despite messages having included important issues such as people's health and safety.”
moderate“Staff told us they had not had the opportunity to meet individually with senior staff since the previous manager left”
person centred care
3 findings
minor“A few people told us they had recently commenced new packages of care but had yet to be contacted by office staff to give their feedback on how things were going.”
moderate“Office staff scheduling care calls to people did not always respect people's preferences for their care staff to be a specific gender. 'I've had men shower me. It's out of order.'”
moderate“when staff were asked whether peoples' care plans were easy to follow, 11 staff had replied 'no'. There was no action as to how the provider intended to address this staff response.”
communication with families
3 findings
moderate“one relative who was POA to their family member... a staff member had visited their family member last weekend and asked them to sign a document that was also back-dated.”
moderate“I phone the office and no-one answers, they don't phone to tell you your call is not happening. There is no communication.”
moderate“Results showed 53% of people felt they were not always dealt with in a prompt way...actions did not include how the provider intended to increase this [response rate].”
medication management
2 findings
critical“one person had, on one day, been given a 2.5mg dose of their blood thinning medicine instead of 2mg and following this error, there was no evidence of medical advice being sought”
critical“They sign the MAR to say they have given the inhaler when they have not, or they don't sign the MAR at all”
incident learning
2 findings
moderate“accident and incident reports were not consistently logged at the office and there was no overall system in place for accident analysis and actions were not always taken”
critical“we identified a police incident during January 2019, which they had not told us about...they acknowledged they had overlooked sending us the required notification.”
safeguarding
2 findings
critical“the local authority had written to the provider regarding one safeguarding incident and had requested a response by 24 May 2018. No response was included in the records.”
critical“concern had been recorded but there was limited detail about the actions taken or agreed. This meant we could not be assured the person was safe.”
complaints handling
2 findings
moderate“People's complaints and concerns, however, were not used to improve the quality of the service. People did not always feel issues they raised were resolved because the same arose again.”
critical“complaint had been made in August 2017 regarding missed and late care calls... this complaint had not been recorded”
leadership
2 findings
moderate“The service had not a registered manager in post registered with us since July 2017... manager, deputy manager and compliance manager were unable to tell us their clearly defined roles.”
moderate“No one wants to take responsibility for what is going on... New manager is not approachable. Probably, because we never see them.”
staffing levels
2 findings
moderate“I have five minutes allocated between two visits to people and the distance between these people's addresses is at least a fifteen or twenty-minute drive.”
critical“one staff member had been allocated an additional 53 care calls in one week during August 2017”
infection control
1 finding
moderate“They are wearing the same gloves they've had on to clean my commode... Staff don't wash their hands here, they tell me they have their own anti-bacterial wipe.”
staff competency
1 finding
critical“new staff are not signed off (as competent to administer medicines) but are still doing medication”
consent capacity
1 finding
minor“two care plans for people we were told had fluctuating capacity. This was not clearly documented on care plans.”