critical“Topical medicines had not been documented accurately or consistently in care plans and daily notes. As a result, it was not clear whether people required support in this area”
moderate“We identified some gaps in these charts including missed signatures and staff not recording the required code, when someone refused their medicines or family had administered them.”
staff training
2 findings
critical“The provider's training records were also inconsistent, which meant we could not confirm the competency of staff.”
moderate“At least three staff were recorded as having completed all eight training sessions on the same day...which would not be possible. The registered manager told us this was a recording error.”
governance
2 findings
critical“Systems and processes to monitor the safety and quality of service provision, identify issues and ensure actions were addressed timely, were not robust or fully embedded.”
moderate“The provider did not have a clear audit schedule in place, which detailed what areas were checked and how often.”
supervision appraisal
1 finding
critical“Staff had not received supervision in line with the providers policy, to support them in providing effective care and promote personal development.”
care planning
1 finding
critical“Care records were not always accurate or detailed people's preferences.”
person centred care
1 finding
moderate“Care plans viewed on inspection tended to be task orientated...there was limited personalised information about people's likes, dislikes, interests, preferences”
leadership
1 finding
moderate“Due to the registered manager also being the nominated individual and owner of the company, there was no independent oversight of the service to ensure governance processes were robust.”
incident learning
1 finding
moderate“Accidents and incidents had been documented. However, this just detailed what had occurred, with no further information recorded, such as action taken, outcomes and lessons learned.”
missed or late visits
1 finding
moderate“rotas viewed indicated inconsistent travel time between calls. We noted numerous examples where no travel time had been scheduled between calls.”
infection control
1 finding
moderate“Changes to testing guidance for care staff had not been implemented timely. Not all staff were completing LFD tests before each shift.”
complaints handling
1 finding
minor“The outcome section of the current log was very brief and did not explain action taken, outcomes and lessons learned.”
communication with families
1 finding
minor“we did not see or were provided with examples of information being available in different formats, such as large font, easy read or audio files to cater for varying needs.”
safeguarding
1 finding
minor“the initial concerns reported, action taken, and outcomes had not been captured on a safeguarding log.”
record keeping
1 finding
moderate“we found instances of contradictory information within care plans. For example, one care plan stated a person's family managed their medicines in one section, whilst in another section stated staff needed to support them”