critical“Entries made on MAR charts were not always consistent with the pair of staff who had signed the daily records of care which made it hard to establish who had provided medicine support.”
moderate“some people's medication administration records (MAR's) had gaps and these coincided when people had been supported by their relatives with this area of their care”
critical“Planning and recording of medicines were not always consistent and in line with the provider's own medication policies and procedures.”
record keeping
3 findings
critical“Records of care delivered were not always accurate, complete or legible. This meant that in some circumstances we were unable to establish the full details of the care and support.”
moderate
“the MARs needed to be fully completed in-line with guidance to ensure records were kept accurate and any risks regarding missed medication mitigated”
critical“we continued to find examples of records related to people's care or medication not being complete and accurate, such as risk assessments and medication assessments.”
governance
3 findings
critical“Systems to assess, monitor and improve the service were not sufficiently robust. Daily records from January 2021 which showed shortfalls had not been audited prior to our inspection visit.”
moderate“issues regarding the recording of medication and this had not been identified and addressed previously during the registered manager's internal audits”
critical“The quality assurance procedure in place had not been effective in identifying the issues found at this inspection and in driving the necessary improvements.”
care planning
2 findings
moderate“People did not have a medicine assessment detailing the exact nature of the support they required with their medicines. Care plans needed more detail.”
critical“The mock care records we reviewed did not always contain comprehensive risk assessments.”
incident learning
2 findings
moderate“Care plans had not been updated following incidents with additional strategies to help guide staff. One incident response was not suitably robust.”
moderate“the registered manager did not show a good understanding of how they would use this information to look for trends and patterns and improve the provision of service.”
leadership
2 findings
critical“The registered office was based in Leeds, but most care packages were being delivered in Somerset. There was inadequate governance to manage this safely.”
critical“The governance systems in place were not robust enough to demonstrate the registered manager had the appropriate oversight to safely manage the service.”
person centred care
2 findings
minor“staff were, at times, task focused... 'they don't really chat to [them] otherwise'... 'they whizz in and out'”
moderate“the person had specific communication needs and staff had to support them in a particular way, however, there wasn't a communication care plan in place.”
staff training
1 finding
critical“Staff had not received any practical training or competency assessment in moving and handling, despite using a range of equipment such as slide sheets, stand aids and hoists.”
safeguarding
1 finding
critical“Because of the issues with staff recruitment checks we did not feel completely assured about safeguarding. It was not always clear from records who had provided care and support.”
staff competency
1 finding
critical“Safe recruitment practices were not consistently followed. Up-to-date DBS checks had not always been obtained when staff started work.”
end of life care
1 finding
moderate“No information on people's end of life arrangements were recorded. Care records did not contain end of life care plans.”
infection control
1 finding
moderate“A COVID-19 risk assessment was provided an hour and a half after requested, however it was not at all relevant to the service and mentioned another organisation throughout.”
consent capacity
1 finding
moderate“The registered manager's knowledge of the principles of the MCA was good, but less consistent in how to apply it.”