moderate“The amount of medicines received from the pharmacy was not always recorded on people's medicine records. This meant that it was difficult to audit the stock balance.”
minor“One person had three tubes of the same cream in their cupboard without dates on to show when they had been opened or which should be used first.”
moderate“One person's medicine record stated that a medicine should be taken three times per day. However, records showed that it had only been administered once per day for a number of weeks.”
critical“On one person's MAR there were eight blanks for a medicated cream over the previous four weeks. The codes to identify the reasons for this were not used.”
moderate“Care records for a third person contained a list of medication they took which was incorrect.”
supervision appraisal
3 findings
minor“Annual appraisals had not been completed for most staff in the past twelve months. The registered manager was aware of this and told us they had not had the opportunity to complete these since being in post.”
moderate“We looked at the supervision notes for these staff and saw that the incidents had not been explored with members of staff during these meetings.”
moderate“records relating to staff supervision were not maintained.”
governance
3 findings
minor“We found that the previous rating was not displayed on the provider's website. We raised this during the inspection and it was actioned straight away.”
critical“Systems and processes had not enabled the registered person to assess, monitor and improve the quality and safety of the services provided to people.”
critical“Systems and processes did not operate effectively to assess, monitor and improve the quality and safety of the service provided.”
record keeping
2 findings
critical“Medication that was not blister packed was not being counted and stocks recorded. Therefore, it was impossible to know if the stocks held were correct.”
critical“Records were out of date and inaccurate. This included medication records, care plans, staff training and supervision records and policies.”
staff training
2 findings
moderate“Some training that people's care plans identified as necessary did not appear on the training matrix; for example dysphagia, mental health awareness and specific syndromes.”
moderate“One member of staff told us training had often been cancelled and not re-arranged. They said this included training on how to meet people's health care needs.”
care planning
2 findings
minor“In one person's file it indicated the person had capacity to consent to their care and an assessment had concluded that they did not.”
moderate“A third person's care plan had been written in December 2013 and had not been reviewed.”
person centred care
1 finding
minor“We did however observe two staff members entering a person's flat without knocking or explaining to the person why they were there.”
incident learning
1 finding
critical“One team there was a pattern of physical incidents against members of staff. The team had documented 23 physical incidents between January and May 2017.”
leadership
1 finding
moderate“The agency does not have a registered manager. There is a manager in post who has not yet registered with the CQC.”
safeguarding
1 finding
critical“The agency did not report these incidents under safeguarding adult's procedures.”
missed or late visits
1 finding
critical“staff had arrived at a person's house at 11 am instead of 8 am. On arrival staff found the person had fallen and been unable to get up.”
consent capacity
1 finding
critical“No written assessment of the person's capacity to make this decision was recorded and no 'best interest meeting' had been held.”
complaints handling
1 finding
moderate“We asked to see the complaints log but one was not produced...There was not a clear audit trail of the complaints and the action being taken.”
communication with families
1 finding
moderate“Several relatives and people using the service told us that they had not always been able to speak to someone senior in the office when they had concerns.”