critical“Systems had not been embedded within the service...risk assessments had not always been completed, care plans lacked person-centred detail, staff supervisions and spot checks had not been consistently carried out.”
critical“The registered manager had failed to notify CQC of a notifiable event in a timely manner. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
critical“Monthly reports...were completed up to August 2016 but none had been completed between August and December 2016.”
critical“Although the audits were being consistently completed and the errors were being recorded, there were no actions taken to prevent re-occurrence.”
care planning
3 findings
critical
“Risk assessments were not always in place and people's specific and complex needs were not fully and effectively recorded.”
moderate“care plan failed to reflect that the person had mental health needs and a learning disability. This information was only seen in an older NHS document”
moderate“Care plans did not always include details such as how people liked their hot drinks or what they liked to talk about...staff stated that care plans were not sufficiently detailed.”
medication management
3 findings
critical“There was conflicting and confusing information regarding the application of prescribed topical creams. Care plans did not contain clear guidelines to staff about where cream should be applied.”
critical“MAR sheets did not list individual medicines, prescribing instructions and were not signed in.”
critical“In May there had been 42 errors and in April there had been 70. We were not assured that people were being assisted to take their medicines safely or as prescribed.”
incident learning
3 findings
critical“There was no evidence of any analysis to identify trends and themes within the service around accidents and incidents...no analysis of falls or specific incidents to prevent re-occurrence.”
moderate“The registered manager had not submitted one notification to us relating to a safeguarding incident.”
moderate“There had been eight accidents or incidents since January 2019 and, although they had all been recorded, none of them had outcomes of lessons learned.”
missed or late visits
3 findings
moderate“Sometimes they do miss calls and they're not always on time...I don't always get informed when they are running late.”
moderate“The bed time call should have been made between 19.30 and 20.30 and there was evidence of that call being delivered as late as 23.00.”
critical“out of three people's visit records, an average of 8 out of 18 visits were between 20 minutes and 1 ½ hour late. This is just under 50%.”
person centred care
3 findings
moderate“People were not always involved in creating their care plans...Care was not always person centred, people often had their religion recorded but were not asked about their cultural preferences.”
moderate“Care plans were not always person centred and did not contain important personal information, such as diagnoses.”
moderate“the registered manager had failed to promote person-centred care...care plans were not always person centred, people's needs were not always met.”
supervision appraisal
3 findings
moderate“Staff supervisions and spot checks had not been consistently carried out. This placed people at risk of harm due to inconsistent care.”
minor“appraisals did not highlight areas for improvement, set goals for the coming appraisal period or assess the overall performance of staff”
minor“At the last two staff meetings the agenda was the same and there were no notes or records of what any staff members had said.”
record keeping
3 findings
moderate“One person's risk assessment stated they had a weakness on their right side however, the care plan said it was their left side.”
critical“One person had been assessed by a speech and language therapist as needing a special soft diet...the person's care plan was not updated to reflect these changes”
moderate“hand written medicine administration records (MARs) did not have double signatures to show that staff had checked the medicine list, dosage or frequency.”
safeguarding
2 findings
critical“A recent notifiable incident had not been reported to safeguarding. Therefore, we could not be assured that all incidents and accidents were reported to CQC or safeguarding appropriately.”
critical“codes for key safes attached to people's properties were sent out in rotas to staff members via staff members' own private email addresses”
staff training
2 findings
critical“Training records showed some staff had not received refresher training about key aspects of care and support, including safeguarding adults, for over a year.”
moderate“one member of staff, who was assessed in March for medicines, proceeded to make four errors in May. Nothing had been done in response to these errors.”
staff competency
2 findings
moderate“Training had not been completed by staff who cared for people with these specific health conditions such as muscular dystrophy and brain injuries.”
critical“one staff member had started working at the service before it had been established that they were suitable...A DBS was issued later that was not clear and which indicated a risk to others”
consent capacity
2 findings
moderate“Decisions about mental capacity had been made for some people, however, there was no record to show how these decisions were assessed.”
critical“two people had bed rails...the registered provider hadn't identified that the use of bed rails could potentially amount to a restrictive practice”
end of life care
2 findings
minor“Care plans did not contain information regarding peoples end of life care. There was a reliance on individual staff knowledge to enable people to receive appropriate support.”
minor“There wasn't a large amount of information available in care plans for staff around person centred end of life care...There was a reliance on individual staff knowledge.”
complaints handling
2 findings
moderate“responses to complaints that were not person centred or receptive to the concerns raised meaning that opportunities for improving the quality of service...were missed”
critical“The complaints records showed that none of the complaints had been responded to in writing and no lessons had been learned or recorded.”
staffing levels
2 findings
critical“out of 10 days' records we examined there were nine care calls (out of 40) where only one carer had delivered care”
critical“Recruitment checks were not always completed to ensure staff were suitable. Two out of the four staff files we reviewed did not include two references.”
communication with families
1 finding
moderate“They don't ring me if they're late, I ring them...I don't know who the staff in the office are. No one rings me from the office.”