critical“Medicine names where spelt incorrectly, and wrong doses were handwritten. People's allergies were not recorded on the MARs we reviewed.”
critical“eMARs viewed did not always record how and when to take medication, including frequency of medicines.”
critical“For 1 person we found their pain relief was not being administered safely. This person was administered paracetamol too closely together.”
consent capacity
3 findings
critical“Where people's capacity was in doubt, the provider had failed to ensure decision specific capacity assessments were carried out.”
critical
“consent to care were signed by relatives even if the person had a capacity. In 1 person's care plan it said, 'I have full capacity', however, the consent to care was signed by a relative.”
critical“The provider did not carry out mental capacity assessments when they were required to do so.”
care planning
2 findings
critical“Care plans contained contradictory and inaccurate information and lacked enough detail for staff to provide person-centred, safe and effective care.”
minor“further work was still required to ensure people's long-term conditions provided person centred detail on how their condition impacted them, rather than generic statements.”
governance
2 findings
critical“The provider had not established robust systems and processes to assess, monitor and improve the quality and safety of the service.”
critical“system of checks had not been consistently effective as it had not identified and addressed the issues we found during this inspection.”
staff training
2 findings
moderate“New staff received a 1-day induction prior to starting work at the service... staff were not provided with enough time to develop their learning.”
critical“2 staff members delivered support to a person with Percutaneous Endoscopic Gastrostomy (PEG) 6 times in 1 month without having appropriate training in place.”
record keeping
2 findings
moderate“Record keeping in relation to people's daily care was at time illegible to read, lacked detail and completeness.”
moderate“Not all of the training was recorded on the training matrix. For example, there was no records regarding PEG, stoma or catheter training.”
staff competency
2 findings
critical“Professional references were not always obtained when a candidate had previously worked in care, and gaps in employment history were not explored.”
moderate“a person who delivered stoma and catheter training did not have the appropriate trainer's qualifications in place to deliver this training.”
staffing levels
1 finding
critical“50% of calls were either scheduled with no travel time or at the same time as other calls... more than half of people's planned care time was not delivered.”
missed or late visits
1 finding
critical“Sometimes they don't turn up at all, usually on a Friday when it's not the regular carer... A few times recently they haven't turned up at night.”
safeguarding
1 finding
critical“We made a safeguarding referral to the local authority regarding a concern for a person's safety during the inspection.”
leadership
1 finding
critical“The registered manager had little oversight of the day to day running of the service and worked at the providers other location based in Yorkshire and stated they just visited the service twice a month.”
person centred care
1 finding
moderate“There was little or no background information about people or their choices, likes and dislikes. Care records did not contain any detail about people's cultural or religious needs.”
incident learning
1 finding
moderate“The provider did not learn from complaints raised about the service. We found similar themes of complaints reoccurred.”
communication with families
1 finding
minor“We have never been asked for any feedback on the service. Some feedback opportunity or other involvement with how things are going would be good.”