critical“At the last inspection time specific medicines were not always administered at the correct time.”
critical“Staff were not aware of the side effects of people's prescribed medicines, and there was no information or guidance recorded in people's care plans about these.”
critical“I don't check this as it's on the box, so I follow that. This meant staff administered medication in an unsafe way and placed people at risk of harm.”
critical“one person required time sensitive medicine to treat an infection. The service did not plan visits from care staff, or record administration outcomes effectively to ensure the person received their medicine correctly.”
critical“A safeguarding enquiry substantiated concerns about a person being over medicated with diabetic medicine due to care call times being too close together. This caused the person to fall into a deep sleep.”
safeguarding
3 findings
critical“During the last inspection the system for reporting abuse was not clear for staff or managers.”
critical“The registered manager had not always reported these to the local authority's safeguarding team. They had not always put measures in place to minimise risk of further abuse.”
critical“The provider received whistle-blowing information regarding potential risk of abuse, however failed to comprehensively investigate the concerns or inform the local authority safeguarding team.”
governance
3 findings
critical“At the last inspection some audits were not thorough or regularly undertaken and therefore ineffective.”
critical“The provider's governance systems were not effective and had not enabled them to continually assess, monitor and improve the quality and safety of the service.”
critical“The providers governance and quality assurance processes failed to provide effective oversight in identifying and monitoring risks for people. Auditing of care records was not thorough.”
care planning
2 findings
moderate“During the last inspection we found care plans did not always contain information about people's health conditions.”
critical“People's care plans and risk assessment did not always provide staff with information on guidance on people's individual risks, such as those associated with epilepsy and Parkinson's disease.”
incident learning
2 findings
moderate“Lessons learnt were not always identified through the Trend analysis and Safeguarding audits or fed back to the staff team.”
moderate“Lessons were not learned following previous incidents regarding medicine management.”
infection control
2 findings
minor“Some people told us not all staff wore PPE. One person told us, 'They are slipping a bit with masks'”
moderate“People and staff did not have individual COVID-19 risk assessments in place for use in reducing associated risk of transmission during care visits.”
staff training
1 finding
moderate“During the last inspection staff were not always trained in peoples specific health conditions.”
record keeping
1 finding
moderate“There was conflicting information in people's care plans, meaning staff may support people unsafely, depending on which part of the care plan they followed.”
missed or late visits
1 finding
moderate“People and relatives told us they were concerned about care call times being changed without them being made aware.”
staff competency
1 finding
moderate“Staff we spoke with were not always aware of people's individual risks or how to offer support to people in line with their specific needs.”
staffing levels
1 finding
critical“one person experienced 73 changes to their scheduled call start times in one month and 14 care calls were either too early or late.”
supervision appraisal
1 finding
moderate“Not all staff were provided with consistent supervision sessions... three of the 25 staff employed did not receive supervision within this timescale.”
cultural competency
1 finding
minor“the service's assessment documentation did not include sections to identify people's race or ethnic background, gender or sexual orientation.”
complaints handling
1 finding
minor“one relative told us 'We have made many complaints to the office, but they don't take any notice.'”
leadership
1 finding
moderate“Staff described working within a negative and unsupportive environment. Several staff we spoke with said they were leaving the service or intended to do so due to increased work pressure.”