critical“Where people were at risk of pressure ulcers, there was not a clear assessment of this level of risk...the risk of pressure ulcers had not been assessed using a reliable tool”
moderate“one person's pressure ulcer risk assessment had looked at factors such as the person's age and skin condition, but had not considered the person's reduced mobility or history of malnutrition”
critical“Care files did not contain information about which medicines people had been prescribed, the support they needed to take them, or any side effects.”
missed or late visits
3 findings
critical“The most recent data showed 60% of care calls took place within 15 minutes of the scheduled time. However, this meant two fifths of calls still deviated significantly”
moderate
“another relative said, 'I've had to chase a couple of times when they've been really late. It's happened a few times and it would be nice to be informed.'”
critical“Overall only 45% of visits took place within 15 minutes of their scheduled time. One member of staff attended visits outside of the schedule 77% of the time.”
governance
3 findings
moderate“two people's records had not been checked for five months and another had no records on file from the last six months”
moderate“although we found some shortfalls in the quality of care including the above issues with communication, the registered manager had identified these and had plans in place to address them.”
critical“The provider's systems to check and audit care had not identified or addressed the significant concerns that we raised during this inspection.”
record keeping
3 findings
moderate“On some occasions, when only one carer instead of two have visited, the log book is signed as if both did attend”
moderate“the office had failed to replace medicines administration record sheets when the supply ran out, meaning staff had to record medicines using daily log sheets instead.”
moderate“There was no tracker for this and we identified multiple instances where people's daily notes and medicines records were not available.”
incident learning
2 findings
critical“Records showed there had been 11 missed visits to this person within 26 days leading up to the hospital admission...The provider had not reviewed the person's risk management plan”
moderate“A care worker had recorded a person had suffered an injury during their visit in the daily logs, but this was not captured in the incident recording systems.”
staffing levels
2 findings
critical“staff rushing or leaving early because they did not have enough time to complete their tasks, and unreliable staffing at weekends with late and missed calls”
critical“Records showed there were occasions when only one care worker attended when two were required to deliver safe care.”
medication management
2 findings
moderate“Where people received medicines within blister packs, staff signed MARs to show all tablets had been administered rather than signing for each individual medicine”
critical“Staff had recorded administering both paracetamol and co-codamol to one person on 17 occasions... risk of liver damage if too much paracetamol is taken.”
supervision appraisal
2 findings
moderate“for almost half of the staff it was not clear in the provider's records whether appraisals were taking place when due”
moderate“Half of the staff files contained regular supervisions in line with the provider's policy, but the remainder didn't contain any supervisions.”
complaints handling
2 findings
moderate“In one case, the relative complaining had sent three emails asking for a response but there was no evidence that the provider had responded at all”
critical“A relative said, 'Yes, we did make a complaint, but it fell on deaf ears.' Records did not always show what was done in response to complaints.”
consent capacity
2 findings
moderate“there was not always evidence of appropriate procedures being followed to ensure decisions about their care were made in their best interests, in line with the MCA Code of Practice”
moderate“Several files where relatives had signed to indicate consent on their family member's behalf... provider had no records to demonstrate that relatives providing consent were lawfully authorised.”
safeguarding
2 findings
moderate“Safeguarding investigations did not always have a clear outcome recorded and it was not always clear whether investigations were still under way or what the next steps were”
critical“Records showed that recent safeguarding concerns raised by the local authority had been shared with the provider. Records showed CQC had not been notified.”
cultural competency
2 findings
minor“there was information about people's religious beliefs but not about how this might impact on how their care was delivered, such as whether they needed to receive support from staff of the same gender”
minor“The service did not consider the impact people's religious beliefs, cultural background, sexual and gender identity had on their care preferences.”
person centred care
2 findings
moderate“care plans did not contain information about the support people needed to manage their health conditions, including symptom control and pain management”
critical“One person's care plan stated, 'support with personal care' with no information about what elements of personal care this person required support with.”
communication with families
2 findings
moderate“People told us they often did not know in advance which staff would be visiting them and were not always told when staff were running late.”
moderate“Another relative said, 'Complaints take a long time from Medacs. They don't communicate by phone or email.'”
end of life care
2 findings
minor“there was very little evidence in care plans that the service had explored people's individual preferences about the care they wished to receive at the end of their lives.”
moderate“These care plans lacked information about people's wishes and what was important to them at this stage of their lives.”
staff training
1 finding
critical“More staff were now out of date in their safeguarding adults, health and safety and food hygiene training.”