critical“I haven't had any training with medicines and my competencies have not been checked. Another person: I haven't had medicine training yet. This person was supporting people with their medicines.”
moderate“On the medicine administration record (MAR) for one person on six occasions in October 2021, the staff member could not give the person their eye drops as they had not been trained in this task.”
care planning
2 findings
critical“4 out of 5 risk assessments we reviewed did not contain information relating to people's risks. Care plans were ineffective at providing guidance to staff, exposing people to the risk of harm.”
moderate“People's records were in the process of being reviewed as some contained conflicting information leading to uncertainty about the accuracy and relevance of the information.”
record keeping
2 findings
critical“The provider had failed to ensure there were accurate and complete records in respect of each person, to evidence the care and treatment provided to them was in line with their assessed needs.”
moderate“We saw on one person's November 2021 MARS, there were several gaps with no staff signatures and no explanations recorded on the MARS.”
governance
2 findings
critical“Audits were either not undertaken regularly or in some instances were not completed at all. No audits of medicines administration records (MARs).”
critical“Systems were not always in place or effective to ensure all documentation was accurate and up to date. Whilst there were some quality assurance checks carried out, these were not always effective.”
staffing levels
2 findings
critical“2 members of staff had been working without a DBS. We did not see any risk assessments in place to mitigate the time period.”
moderate“The registered manager confirmed there had been staffing shortages, due to COVID-19, general staff sickness and the ongoing challenge of recruiting appropriate new staff.”
supervision appraisal
2 findings
moderate“Supervisions were not conducted, and spot checks were inconsistent. The provider was unable to demonstrate systems in place to determine when spot checks were due or had occurred.”
minor“There was a staff spot check and supervision spreadsheet in place, however, it was difficult to assess accurately how often staff were receiving this type of support as dates varied.”
staff training
1 finding
critical“Training records were missing training information such as; diabetic care, eye drops, PEG training. The training matrix did not contain information for all staff working for the company.”
incident learning
1 finding
moderate“Records did not show actions taken in response to incidents. There was no evidence the service had undertaken an audit or wider analysis of accidents and incidents to identify themes or trends.”
safeguarding
1 finding
moderate“Records did not confirm all staff had received training in safeguarding adults. Staff were not always sure who to contact if they had wider concerns such as the local authority.”
infection control
1 finding
minor“A chap who turned up without a uniform and occasionally the males don't wear aprons. Management was unsure of when this message was communicated to staff.”
person centred care
1 finding
moderate“People's views and decisions about support were not always incorporated in their support plans. This meant staff were not always aware of how to support people in a way that allowed people to have control.”
leadership
1 finding
moderate“I feel like I'd be shut down if I suggested a change. Staff did not always feel they were involved within the service development or given an opportunity to be heard.”
missed or late visits
1 finding
moderate“There was no system for recording late visits to people, which meant the registered manager had no way of checking how many occurred, if any.”