critical“A statin for high cholesterol…recorded on the MAR as administered twice [on 4 days] which had not been identified in the MAR audit.”
critical“The reason why a PRN medicine had been administered was not recorded to ensure it was given appropriately and as prescribed.”
critical“Medicines were not managed in a safe way. The medicine administration record (MAR) did not contain information on whether the person had any allergies or information on the person's GP.”
care planning
3 findings
critical“Where a person's care needs had changed this was not reflected in their care plan to ensure staff were providing the support to meet the person's current needs.”
moderate
“The care plans for some people were still focused on the care tasks and did not always provide information on how the person wanted their care provided.”
critical“Care plans lacked detailed and guidance for staff. Care plans lacked information about people's backgrounds, interests and things that were important to them.”
staff training
3 findings
critical“Staff were providing support for people living with diabetes and Parkinson's Disease but there was no record of the staff members completing training in relation to these conditions.”
moderate“3 did not have any records of an induction being completed before they commenced providing care and support.”
critical“Staff had not always received training specific to the needs of people they supported. There were staff that regularly supported people with Parkinson's and diabetes, yet no staff had received training on this.”
consent capacity
2 findings
critical“Mental capacity assessments had been completed but these did not consider the specific aspects of the care provided to identify if the person could consent.”
critical“The provider and registered manager were not aware of the principals involved to safeguard the rights of people who were assessed as being unable to make their own decisions.”
governance
2 findings
critical“The provider's quality assurance systems were not operated effectively as they were still in breach of the regulation and Warning Notice.”
critical“There was a lack of auditing by the provider and registered manager to identify where improvements needed to be made... None of these areas had been audited.”
record keeping
2 findings
moderate“Care records did not include enough detail about people's care needs and associated risks and were not always up to date.”
moderate“We saw from the daily notes for people that staff were not accurately recording when they arrived and left a person's home.”
communication with families
2 findings
minor“People and relatives informed us they were rarely, if ever, informed if the staff member was running late for a visit.”
moderate“People and the families were not always told when care staff were running late. One relative said, 'There is no point ringing her cos she has dementia, they really need to ring me if they're running late.'”
person centred care
2 findings
moderate“People's care plans did not always include information on the person's communication support needs and how staff could assist them.”
moderate“People life histories, likes, dislikes and interests were lacking in their care plan... Staff we spoke with were not familiar with people's life histories.”
incident learning
2 findings
moderate“Checks carried out on the records completed by staff did not always clearly show important information had been escalated to senior staff or the person's relatives.”
critical“Accidents and incidents were not always recorded with the actions taken to reduce further risks... The registered manager was not collating all the incidents and accidents.”
staffing levels
1 finding
critical“Staff were not always given enough travel time in between calls. We saw from one rota that a member of staff was given five minutes to travel from one person to another.”
staff competency
1 finding
critical“One member of staff, who had no background in care, had only completed two care calls and then started providing care independently the following day.”
supervision appraisal
1 finding
moderate“When we reviewed staff files, we saw there were staff that had only received one supervision since July 2022.”
safeguarding
1 finding
critical“Staff had a lack of understanding of what they would do if they needed to report the concerns outside of the organisation. Staff we spoke with did not know who the agency was that dealt with safeguarding.”
leadership
1 finding
critical“The provider and registered manager were not open and transparent with us at the inspection... The provider said, 'We added those names just to populate the staff as we don't want you to know.'”
end of life care
1 finding
moderate“People were not always supported with their end of life care planning. There was no information in their care plans on discussions with them and their relatives on their wants and wishes.”
missed or late visits
1 finding
moderate“People and relatives told us that in the main staff arrived at the calls. However where two staff were required to support a person on each call this was not always taking place.”
infection control
1 finding
minor“Relatives fed back that staff were not always wearing personal protective equipment.”