critical“we found calls where staff were logged in at 2 different people's addresses at the same time.”
critical“Staff had commenced their employment, some working many months before a Disclosure and Barring Service (DBS) check had been carried out.”
medication management
2 findings
critical“a staff member had dispensed a person's medicines and left them in a pot next to the bed for the person to take when she arrived home. The staff member signed the MAR chart.”
moderate“Medication administration records for a person had some missed staff signatures. This meant the provider could not be assured the person had received their medication as prescribed.”
staff training
2 findings
critical“a staff member had no record of training for medicines awareness, falls awareness, health and safety and learning disability training.”
critical“Staff training matrix had gaps showing some staff had not undertaken training in key topics related to people's safety such as infection prevention measures, safeguarding and health and safety.”
governance
2 findings
critical“The provider had falsely completed an audit of a person's daily notes... completing audits of the notes (which they were not in possession of) and recording there were no issues.”
critical“The provider had failed to ensure sufficient systems and processes to monitor the safety and quality of the service provided were in place and were robust and effective.”
record keeping
2 findings
critical“Audits were not always effective as staff were auditing their own records... the daily care records were then audited by the same carer who made the error.”
moderate“The registered manager had not audited people's medication administration records and was unaware staff were not always signing records.”
safeguarding
2 findings
critical“A person was assessed as lacking capacity around medicines... the person had full access to all their medicines, placing them at risk of significant harm.”
moderate“Staff stated they would alert the registered manager to any concerns they had about potential abuse. However, they were not fully confident in all types and forms of abuse.”
missed or late visits
1 finding
critical“staff had been 45 minutes late to support people... staff had stayed for less than half of the allocated time people had to receive their support.”
care planning
1 finding
moderate“a person's records stated the person had a walking frame, but another document stated there was no equipment used by this person.”
leadership
1 finding
critical“The provider failed to be honest and transparent with CQC... they told us they employed 35 staff at our initial inspection, but sent a training matrix to the local authority which contained 42 staff names.”
consent capacity
1 finding
moderate“Mental capacity assessments had not been completed or were incomplete... people were not always able to make day-to-day choices about their lives.”
supervision appraisal
1 finding
moderate“Staff were not always supported through supervision or had their competency assessed against measurable criteria to ensure they were providing good quality and safe care.”
staff competency
1 finding
moderate“There was no evidence as to the criteria used to determine staff's competency [in medicine management]. The provider's policy referred to staff being assessed; however it did not detail how.”