critical“This system had failed to identify some of the concerns we found on inspection... medication management, out of date policies, application of the MCA, reporting safeguarding concerns.”
critical“The provider's systems had not identified or addressed concerns we found during the inspection. 12 actions did not have a target date for completion”
critical“the registered person had not protected people against the risks of receiving unsafe or inappropriate care by obtaining the views of people about the service”
critical“The failure to notify the commission of safeguarding concerns was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
moderate“the provider had failed to send us a report of actions when requested to do so...This meant the provider had failed to meet a legal obligation.”
moderate“Staff had logged an incident in which a person had 'swung at' their care worker. Their risk assessment...read, '…has never been violent to a carer.'”
medication management
5 findings
critical“Guidance to support the use of medicines prescribed 'as required' (PRN) such as pain relief was not available in people's care plans.”
moderate“checks that staff were competent to administer medicines or that staff were following the correct procedures were not carried out for all staff”
critical“Eight told us they had never had training on medicines with admiral care...All staff confirmed they had never received any competency assessment to administer medicines safely.”
moderate“a 'client profile form' dated 27 January 2016 stated care workers should assist with medicines...The person's care plan dated 2 December 2016 stated that the person's representative would administer”
critical“One person's medicine records were incomplete and contradictory. Lists of medicines in their care records did not include all their prescribed medicines.”
record keeping
5 findings
critical“Information in people's care plans about risks and safety was not always comprehensive or up to date. This included information about skin injuries, prevention and treatment, catheter care.”
critical“Failure to make sure records of people's care and support were up to date, clear and accurate was a breach of Regulation 17 (c)”
moderate“People's care records were not fully completed and care plans were not always completed, reviewed or amended when a person's need had changed.”
minor“The other person's office file contained two out of date 'administration of drugs consent forms'...referred to medicines no longer in the person's prescription.”
critical“Failure to maintain accurate and up to date records of people's care was a continued breach of Regulation 17(2)(c) of the Health and Social Care Act 2008.”
consent capacity
4 findings
moderate“The provider's process for decision making in people's best interests was not followed in their care records... records needed to be correctly completed to show principles of the MCA were followed.”
critical“Care workers who supported people living with dementia were not familiar with the Act or its associated code of practice.”
moderate“Staff did not know what the procedures were if someone they provided care to lacked capacity to consent to care or when a 'best interests' decision needed to be made”
critical“Arrangements for giving medicines covertly were not in accordance with the Mental Capacity Act 2005...mental capacity assessments had not been completed.”
care planning
4 findings
moderate“Information about the level of support people required was not clear for example, whether care staff administered people's medicines or provided a prompt only.”
critical“One person's 'routine on retiring' stated, 'Likes dentures removed? Yes.' Whereas their 'personal hygiene' record stated, 'Wears dentures? No.'”
moderate“No plans of care had been developed for four people following this assessment...Of the four people who had care plans all four care plans were not dated.”
moderate“Their care plan did not contain records to show this risk had been assessed or that the use of a lap strap had been agreed as the least restrictive measure.”
safeguarding
3 findings
critical“Not all safeguarding concerns were shared promptly with the local authority safeguarding team... The registered manager had failed to notify CQC of allegations of abuse.”
critical“13 out of 38 staff had not received the training. Two out of four care workers we spoke with were unable confidently to describe the different types of abuse”
critical“The commission had received 16 safeguarding concerns about the service from the 26 August 2014 to 2 July 2015. The commission had not been notified of safeguarding concerns.”
incident learning
3 findings
critical“2 allegations of abuse and 1 incident reported to the police had not been notified to CQC as required.”
moderate“The provider had failed to identify and appropriately investigate safeguarding concerns... risks were identified in people's care assessments but not followed up by effective risk assessments.”
critical“Of the eight people's care records viewed all incident and accident sub folders were empty...there were no systems to analyse incidents and accidents.”
staff competency
3 findings
minor“One person told us, "There was an instance once with a new person doing it and they didn't know how to change a catheter bag. We were concerned about that".”
moderate“there were no records for four of the five care staff whose records we looked at to show they were observed working with people to check their competency”
moderate“Six care staff said they had never received a spot check or an observation of their work...staff who work unsupervised did not always receive regular competency checks.”
staff training
3 findings
critical“None of the care workers we spoke with were able to speak confidently about the principles of the Mental Capacity Act 2005.”
moderate“Two staff said they had not received any training since they started working for the service approximately 11 months before”
critical“The training manager had not delivered any training to staff except induction for new starters as they had not undertaken the appropriate 'train the trainer' courses.”
leadership
3 findings
moderate“The service had been in special measures since October 2015, but the new management system implemented by the provider did not start until four months later.”
moderate“insufficient checks by the management to ensure that staff performance and behaviour reflected these values”
critical“The registered manager was not always aware of their responsibilities for providing a care service...said they would be stepping down as the registered manager.”
supervision appraisal
3 findings
moderate“The provider had failed to provide staff with appropriate support, training, professional development, supervision and appraisal.”
critical“there were no records of any supervisions or appraisals for any of the five staff records we looked at”
critical“Thirteen out of 14 care staff said they had never received an appraisal...eight care staff confirmed they had never received a supervision session whilst working for the service.”
complaints handling
2 findings
minor“7 people fed back to the service they were not aware of the complaints or compliments procedure, but no actions to remedy this had been identified.”
moderate“There was no evidence of an investigation having taken place or records to show what action had been taken in response to any failure identified by the complaint.”
missed or late visits
2 findings
minor“some people told us that due to low staffing levels and recent staff turnover, sometimes staff members arrived late. One person told us, "They don't have enough people."”
moderate“One morning they were one and half hours late. No one rang me.”
person centred care
2 findings
moderate“People did not always receive care in line with their preferences... calls were not always at the time agreed.”
moderate“People's care plans were task specific and did not take into account how they would like to have their care provided.”
staffing levels
1 finding
minor“some of the relatives thought that due to the recent turnover of staff some of them were rushed into providing care and support to people.”