minor“Some staff had not always been completing an accurate record of the times of visits on one of the systems.”
critical“Many records showed shorter visit times than people were allocated. One person had two visits one day recorded as seven minutes and nine minutes.”
critical“Risk assessments did not address identified risks to people, nor provide plans to mitigate the risk. Risk assessments were confusing as they covered many areas within one assessment.”
critical“The failure to ensure records were kept up to date, to have systems in place to manage the service successfully and to regularly assess and monitor the quality of the service is a continued breach of Regulation 17.”
moderate“Records continued to not be kept up to date or recorded consistently to avoid errors or omissions. Systems and processes were not in place to identify concerns.”
moderate“gaps in people's MAR charts where staff had not signed to say they had given people their prescribed medicines.”
moderate“Improvements were needed around record keeping to ensure that all information was available and up to date to make sure people received safe care.”
moderate“The medicine cabinet temperature and medicine fridge temperature had not been recorded every day.”
moderate“The Statement of Purpose for the services had not been kept under review since April 2012. Information contained in the Statement of Purpose was not up to date.”
governance
9 findings
minor“Some action points had been carried over from one month to the next in the care home maintenance audits. An explanation wasn't given why there was a delay.”
critical“The monitoring systems used in the care agency were not effective in maintaining quality standards... concerns we found had not been identified or actioned.”
critical“Weekly audits to check the quality and accuracy of the care agency records had not been sustained. The first audit was undertaken in December 2018. Following this, no further audits had taken place until 25 April 2019.”
critical“Consistent auditing systems to ensure the clear management and oversight of the service by the provider and registered manager had not yet been evidenced.”
moderate“Weekly health and safety checks had not been completed in the care home since 30 January 2018. One member of staff was responsible... but had not been available and the registered manager had not allocated the task.”
critical“Quality monitoring systems had not been developed to ensure the registered provider and the registered manager had proper oversight of the quality and safety of either service.”
critical“quality monitoring documentation we asked to see such as medicines audits, care plan audits and people's personal finance audits were not available.”
critical“quality assurance and governance systems were not in place to enable the provider to drive continuous improvement at the service.”
critical“Quality assurance and governance systems were not in place and had not been used to drive continuous improvement at the service.”
medication management
8 findings
minor“Guidance was not in place to inform staff to rotate the areas of the body where the patch was placed to avoid skin irritation.”
critical“In August, September and October 2019 the person ran out of their medicines and missed one to two days of their medicines as they had not been ordered in time.”
critical“People's prescribed medicines were not always managed safely in the care agency. Incidents had not always been investigated appropriately to ensure action was taken to avoid similar incidents.”
critical“An incident had occurred on Tuesday 20 March 2018 when a member of staff noted from the MAR that the previous days medicines had not been administered... two reportable incidents had occurred.”
critical“The period between 12 November 2016 and 06 March 2017 no records had been made. Between 15 May 2017 and 31 May 2017 and from 31 May 2017 to 22 June 2017 no records had been made.”
critical“the medication administration records (MAR) in the care home did not always confirm that people received the medicines as prescribed. Three people's MAR charts we looked at showed gaps”
moderate“We found no protocols in place for 'as and when necessary' (PRN) medicines within the DCA service records.”
critical“The medication administration records (MAR) did not always confirm that people received the medicines as prescribed. For one person there were gaps in the recording of medicines administered.”
care planning
8 findings
moderate“Some people's assessments were not complete. Some information was missing. For example, a section entitled, 'What is important to me' was not completed.”
moderate“One person had a catheter in place yet a risk assessment and management plan was not recorded to provide guidance for staff.”
moderate“Care plans in place did not identify known triggers that may cause people to challenge. Nor did they describe what the behaviour may be communicating to staff.”
moderate“Care plan reviews should have been carried out every 10 - 12 weeks, however, one person had not had a review of their care plan since September 2017 and another since October 2017.”
moderate“Although changes to people's care and support needs were recorded each month, the changes were not always reflected in the care plan.”
moderate“Some care plans had not been fully reviewed since October 2015. There was no record that other people involved in the person's life had attended to review the care plan.”
critical“mental capacity assessments had not been undertaken with people living in the care home before care planning decisions had been made.”
moderate“Five people's records showed that they had not had a review since May 2015.”
consent capacity
7 findings
minor“there was some inconsistency in how these conversations and decisions were recorded. Immediate action was taken to ensure staff followed best practice around assessing mental capacity”
moderate“How a decision was reached and evidence to show the decision was in the person's best interest had not been clearly recorded.”
critical“The registered manager was unclear how many people had a DoLS authorisation in place... The other person's DoLS authorisation had expired in November 2018.”
moderate“A mental capacity assessment had not been undertaken to determine if the person had the capacity to consent to the restriction [bed guard], or evidence of the decision having been made in the person's best interests.”
critical“There continued to be no records of best interests meetings having taken place when less complex decisions needed to be made on people's behalf.”
critical“There was no evidence of best interest's decisions within the care home to make sure people's rights were upheld.”
critical“best interests meeting had taken place in July 2009 and there was no evidence the decision had been reviewed since then.”
supervision appraisal
6 findings
minor“formal supervisions were not always as frequent as expected. The provider was working towards make improvements in this area.”
critical“Of the five staff files we looked at in the care home... one staff member had received no supervision, one staff had one supervision meeting recorded. Staff had still not had the opportunity to take part in an annual appraisal.”
critical“Two had no supervision meetings documented and four had one supervision meeting in December 2016 and none since.”
critical“In the care home there were no written records to show that regular supervision had been undertaken with staff.”
moderate“three staff had only one supervision meeting in the last 12 months, one had no observation checks and three had either one or two observation checks”
critical“Staff told us that they had not had regular individual one to one meetings for some time. There were no written records to show that regular supervision had been undertaken.”
missed or late visits
6 findings
minor“10% of people responded that staff did not always arrive on time and their concerns were not always responded to. A plan of action had been put in place”
moderate“They are supposed to come at half past nine, but it can be after eleven o'clock. They didn't come at all last night.”
moderate“Morning care visits varied between 6.30am and 8.40am with no explanations why the visit times changed.”
minor“Many people we spoke with said staff often turned up late. This meant people were kept waiting to receive their care. This is an area that needs improvement.”
minor“The time I requested was 08:30 but they do not come at that time and it has got later and later.”
moderate“The registered manager was unable to find a record of any missed calls to people in the community. The registered manager said that there had been an occasional missed call.”
staff training
6 findings
minor“Some refresher courses had not been completed by some staff, such as diabetes awareness and catheter care.”
critical“No staff had up to date epilepsy training. The last time any staff had undertaken epilepsy training had been in 2016... Six staff had not completed the training at all.”
critical“Out of 20 staff, only three staff had completed dementia awareness training even though staff supported people living with dementia in their own homes; three staff had undertaken health and safety training.”
critical“Out of 17 staff working in the care home, only 12 staff had updated safeguarding adults training, seven had completed first aid training, nine staff had undertaken fire training.”
moderate“There was no evidence of new staff receiving induction training, which provided them with essential information about their duties and job roles.”
moderate“Some staff in the care home needed to refresh training in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).”
leadership
5 findings
moderate“Although the registered manager was aware this was the case and some staff were not fulfilling their role, there was no evidence they had addressed this.”
critical“The provider and registered manager had not been able to achieve a Good rating over five CQC inspections.”
moderate“People who received care and support from the care agency and their relatives told us clearly they did not think the service was managed well.”
critical“The provider continued to have very little involvement in either the day to day management or the strategic direction of the service.”
moderate“The provider did not ensure the registered manager had the support necessary to make the improvements expected following the previous comprehensive inspection.”
infection control
4 findings
critical“We were not assured the provider and registered manager were promoting safety through the layout and hygiene practices of the premises.”
critical“The laundry room was in a poor state of repair and cleanliness. Cracked and chipped concrete flooring was clearly visible...No handwashing facilities were available for staff.”
critical“A planned cleaning schedule was not in place for staff to clean high touch areas regularly throughout the day and night, such as lights switches and door handles.”
critical“Staff were not using consistent practice when putting on and taking off their PPE...where this was kept to ensure safe use when providing individual care had not been carefully planned.”
staff competency
3 findings
critical“No staff in either the care home or the care agency had completed a practical moving and handling training course or had their practical skills tested.”
moderate“The registered manager had not had the correct level of training required to ensure the care home was working within the principles of the Mental Capacity Act 2005.”
critical“A full employment history had not always been obtained for five staff. There were no interview records, and no evidence that any gaps in employment on the application form had been followed up.”
safeguarding
3 findings
critical“Robust recruitment procedures had not been followed to make sure only suitable staff were employed... One staff member had not had an updated DBS check since 2009.”
moderate“A safeguarding procedure or a copy of the local authority safeguarding protocols were not available for staff to refer to in the care home.”
minor“Some of the information about who to contact was not up to date. For example, information about who to contact together with names, addresses and telephone numbers.”
staffing levels
2 findings
critical“Last Sunday only one carer turned up, when there should have been two carers. This has happened two to three times recently.”
moderate“Staff changes had meant the care agency management team could not always deploy staff appropriately... 'No, I don't think they have enough staff to go round so everything is rushed.'”
complaints handling
2 findings
moderate“Not all of these were logged as complaints which meant a robust system was not in place to make sure lessons were learnt from complaints.”
minor“verbal complaints were not recorded as complaints and therefore not analysed in order to learn from mistakes and make improvements to service delivery.”
person centred care
2 findings
minor“Although people clearly liked to do these things, there was no evidence... about new things that had been tried to increase people's choices. People had been taking part in the same activities for many years.”
minor“Individual activity plans or a care plan focusing on people's interests and activities to make sure people were always supported to have meaningful activity each day were not in place.”
communication with families
2 findings
moderate“The provider had not sought feedback from the relatives, friends or other stakeholders of people living in the care home to gain their views of the service provided.”
moderate“'The problem is the office and they never keep us up to date with changes'; 'No continuity at all, none whatsoever. Nothing is ever followed through and notes are never passed from one person to another.'”
incident learning
2 findings
critical“The office staff did complete an incident form, however, no further investigation had been carried out by the care agency manager or the registered manager.”
moderate“Although some audits had been carried out since the last inspection, these were sporadic, and had not continued and no actions had been identified to improve the service.”
other
1 finding
minor“The registered provider failed to display the rating of their previous comprehensive inspection at the premises where the service was provided.”