critical“People did not always get their medicines as prescribed. One person was prescribed a medicine which should have been administered with a four-hour gap between doses. However, the electronic records showed this was not the case.”
critical“In four people's records we found gaps on the MARs which meant there was no way of knowing if the medication had been given as prescribed.”
minor“staff did not always correctly time stamp the exact time medicines were administered, instead recording all administration at the end of the visit”
incident learning
3 findings
critical“Individual accident and incident reports were not monitored by the management team to determine if there were any lessons to be learned. This meant when things went wrong there was no evidence of learning.”
moderate“More minor incidents were not consistently recorded. We found examples of more minor incidents and complaints which should have been logged.”
moderate“There was no analysis of late calls to look for themes and trends, and late calls were not identified if staff failed to ring the office.”
governance
3 findings
critical“Electronic audits were not recent. For example, the last medication audit was completed in December 2017. Care plans and care notes were not audited.”
critical“There were no systems in place to review daily records of care and medication records once they were returned to the office.”
moderate“There also was no central collation or analysis of these incidents which meant that the organisation may have missed opportunities to understand the frequency of these incidents.”
record keeping
3 findings
moderate“The care system was not set up to accurately record which staff had written and updated people's care plans and assessments. One person's name was used against all documentation.”
critical“Some care records were significantly out of date and did not reflect people's current needs.”
minor“the configuration of the system reduced the amount of personalised information recorded for example, about people's choices and feelings”
care planning
2 findings
moderate“People's care plans were basic and lacked guidance around how to support people, for example, one person's plan stated they needed help with washing and dressing but there was no detail about how support should be provided.”
moderate“The person's care plans were not up to date. A message had been sent to care staff on 23 December 2015 which stated the person was staying in bed until lunch time.”
missed or late visits
2 findings
moderate“People's agreed visit times were inconsistent and staff arrived at times that were not always suitable to the person. For example, some people received medicines at the wrong time.”
moderate“When they are late the office said they would contact me and let me know. But this isn't happening I have to make numerous calls to find out when they are coming.”
person centred care
2 findings
critical“Risks to people were not appropriately assessed or managed which placed them at risk of harm. For example, one person's skin care plan stated they had previously suffered a pressure sore. However, there was no risk assessment.”
minor“further detail would enhance the personalisation of these [electronic care records]”
complaints handling
2 findings
moderate“There was no complaints log in place detailing the number of complaints received within the last year, which made monitoring for any trends or themes difficult.”
minor“73% of people were happy with the way the agency and its staff respond well to any complaints or concerns raises, and 25% disagreed that the agency responded well to complaints”
end of life care
1 finding
minor“There was no information in people's care records to show how the service had explored people's preferences and choices in relation to end of life care.”
leadership
1 finding
moderate“Members of the management team did not fully understand how to operate the electronic care system which meant records were not set up currently and data was not checked.”
safeguarding
1 finding
moderate“We found one example where a concern identified by staff was not recognised as safeguarding by the service... it had not been reported to the local authority safeguarding team.”
supervision appraisal
1 finding
minor“One new staff member had six checks done since October but another had not had any who started at the similar time.”
staff training
1 finding
moderate“some staff had received specialist training in some subjects such as dementia care or end of life care, however most staff had not”
consent capacity
1 finding
minor“some amendments were needed to some of the terminology and selection options on the electronic system to clearly demonstrate relatives' involvement was done in line with the correct legal processes”