critical“People's medicines records did not contain enough information when staff reminded or prompted people to take their medicines. There were no records kept about what medicines staff were prompting people to take.”
moderate“the action taken could not always be evidenced. For example, the attitude of two staff had been identified in a complaint, but there was no evidence to support the action”
minor“For one person there was inconsistent information in the support staff provided with a person's eye drops.”
moderate“we found that there were gaps in completion of some medication sheets and that daily records were not always dated clearly. This should have been identified through audits.”
governance
4 findings
critical
“Although the provider's medicines audits had identified some areas that needed to improve, they had not identified all the issues we found with medicines records during this inspection.”
moderate“the registered manager told us there was no formal process of analysis and action plan for the review of records returned to the office.”
minor“policies that we looked at had passed the annual review date.”
critical“Audits and checks were in place but some of these were not robust in terms of care logs and financial records. Documentation and MAR's were not always brought back to the office in a timely manner.”
medication management
2 findings
critical“Records about the support people needed with their medicines were not always up to date and some did not contain enough information to support staff to manage medicines in the most effective way.”
moderate“the service was not always recording the time medicines were administered on the Medication Administration Record (MAR) as per their own guidance.”
staff competency
2 findings
minor“when we spoke with some staff their knowledge was limited in how this might impact them in their role [MCA/DoLS].”
minor“We recommended that more comprehensive competency assessments needed to be developed in line with best practise guidelines.”
missed or late visits
1 finding
minor“Some people did say they would like more consistent call times.”
communication with families
1 finding
minor“Two people and a relative felt communication between 'the office' and themselves could be better, saying on one occasion a call wasn't returned.”
incident learning
1 finding
moderate“Systems were either not in place or were not robust enough to assess, monitor and improve the quality and safety of the service.”
complaints handling
1 finding
minor“the complaints policy required updating to include the correct information about the procedure to follow if people remained dissatisfied after the agencies response”
safeguarding
1 finding
critical“there had been two safeguarding concerns which had occurred within the service but had not been reported to CQC.”
other
1 finding
moderate“Where the service handled money for people, there was no system to ensure financial transactions were brought back to the office in a timely manner to check that the correct procedures were followed.”