critical“one just stated 'Paracetamol' with no details of the strength, how many tablets could be administered, the frequency they could be given or the maximum number”
critical“care workers had signed the MAR on eight occasions to confirm this medicine had been given, with only one of these dates being a Sunday”
critical“MARs were in place. However those we reviewed were poorly completed and it was not clear what medicines had been prescribed or when they had to be administered.”
missed or late visits
3 findings
moderate“morning call had on occasion varied between 08:00 and after 10am and their evening call 19.30 one day and 21.20 the next day”
critical
“Most people and relatives (24 out of 34) said that timekeeping was poor and staff didn't arrive on time and/or stay for the correct amount of time.”
moderate“one person's morning call had varied between 7am and 10am for a period of time in May 2018 and another person's afternoon and evening calls were too close together.”
person centred care
3 findings
critical“Care was not always appropriate and did not always meet people's needs or preferences. A full assessment of people's needs had not always been carried out.”
moderate“There was a lack of information within care records demonstrating an assessment of people's emotional and psychological needs, how to meet them and manage refusals of care.”
moderate“there was no agreed call times within people's care and support plans. One person...was not getting calls at the times they wanted them and had been unclear what the agreed call time was.”
record keeping
2 findings
critical“Records relating to people's care and support were not consistently completed. Systems to ensure compliance with the regulations were not sufficiently robust.”
critical“We uncovered some evidence of false record keeping when reviewing timesheets and daily records. One care staff had written they had attended two different addresses for the same 30 minute period.”
care planning
2 findings
critical“one person lived with epilepsy and the care plan stated if they had a seizure for more than five minutes staff should call 999. This had been written in September 2013”
critical“Some people were without complete care plans. There was a lack of information recorded on how staff should manage people's emotional and psychological needs.”
governance
2 findings
critical“medication administration records were being audited when returned to the office. However, we concluded these were not effective as they had not picked up the issues we identified”
critical“We identified several breaches of regulation and examples of poor service delivery which should have been prevented by robust systems of quality assurance and governance.”
communication with families
2 findings
moderate“a number of people reported they were not always introduced to new care and support workers and did not know who was coming”
moderate“People told us staff were often late and they were often not informed of this. Booked for 7 o clock, but the office starts at 9 o clock so there is no-one to contact when they are late.”
complaints handling
2 findings
moderate“two of these had not been logged and had then later come to the service as more formal complaints”
critical“We found many of these issues with timeliness and record keeping had not been fully resolved despite some being raised as early as February 2016.”
supervision appraisal
2 findings
moderate“some staff had not received supervision for several months and some were yet to complete an appraisal. The registered manager...was unable to locate the documentation”
moderate“During the inspection, the provider told us they were reinstating supervisions and appraisals since we saw many were out of date.”
staffing levels
2 findings
critical“There were insufficient staff deployed to ensure people received a consistent and reliable care service.”
minor“one of the rounds had issues with continuity of staff due to staff vacancy, staff annual leave and sickness.”
staff training
2 findings
moderate“The provider did not have an up-to-date training matrix in place. Due to this it was difficult to see where training had lapsed.”
minor“one new staff member with previous experience had started work without shadowing, instead working as the 2nd staff member on a double up call.”
incident learning
1 finding
moderate“There was nowhere on the form to record the outcome, actions taken or lessons learned as a result. Some accidents/incidents had not been recorded in the accidents file.”
safeguarding
1 finding
critical“We saw information in people's records or from incident forms where CQC had not been informed of safeguarding concerns, including alleged physical abuse and suspected financial abuse.”
leadership
1 finding
critical“A registered manager was not in place. The last manager deregistered in July 2016. There were also two care co-ordinator vacancies.”