moderate“Audits undertaken of staff recruitment files had not always been carried out, it was unclear who had undertaken them and when. Gaps in employment had not been identified through the audit process.”
critical“Audits of care records had not identified areas of concern that had been recorded by staff such as records of falls and seizures.”
critical“Quality monitoring processes were haphazard and did not provide the information the provider would need to be assured of the quality and safety of the service provided.”
critical“The medicines audit was not adequate to pick up areas of practice that were not safe and take action to address the issues quickly.”
critical“An effective system for monitoring the quality and safety of the service provided was not in use...registered manager confirmed they had no evidence of this.”
medication management
5 findings
minor“1 person's MAR showed they were having their thyroid medicine at the same time as other medicines...this had not been identified as a cause for concern.”
critical“Staff were not always doing this and records showed they were leaving medicines out for the person to take at a later time...the person went without their prescribed medicines.”
critical“MAR had only been signed for twice in June 2019 which meant that the person had not received medicines twice within the month. The MAR for April 2019 had not been completed at all.”
critical“One person's daily records for 10 May 2019 showed staff administered Paracetamol gel to the person's back. In the same care visit staff also gave the person two Paracetamol.”
critical“Gaps were found on some people's medicines administration record (MAR)...MAR for May 2018 showed gaps where staff had not signed...evening medicines had not been signed for at all that month.”
care planning
5 findings
minor“People's oral health care plan did not make clear if people needed to be supported with dentures or their own teeth.”
critical“One person lived with epilepsy, COPD, Parkinson's disease, angina and asthma...the care plan did not provide guidance for staff on how to support these needs.”
critical“Health conditions did not feature in the care plan at all. This meant guidance was not in place to make sure staff knew what to do in certain circumstances where concerns may arise.”
critical“One person had a diagnosis of epilepsy... There was no information for staff on how to meet the person's needs when they had a seizure.”
critical“The information in the care plan was basic and did not always provide the level of information needed to ensure care and support was consistent.”
record keeping
4 findings
moderate“Medicines records were not up to date. One person's care plan stated they self-administered all their medicines. However, daily care records showed staff were administering medicines.”
critical“Failure to record accidents and incidents means that lessons cannot be learnt, risks to people's safety is not reviewed and assessed in a timely manner.”
moderate“Records were not accurate, complete or contemporaneous. There had been no robust audits or checks of the service completed since our last inspection.”
moderate“The medical or health related conditions people had been diagnosed with and the health and social care professional staff who supported them was not recorded.”
staffing levels
3 findings
critical“Applications forms had not been checked to ensure applicants gave a full employment history. 3 of the 4 staff application forms had gaps in the employment history that had not been accounted for.”
moderate“A staff member had a care call from 08:30 until 09:00 and the next care call was at 09:00...nine care calls in one day with no travel time allocated.”
moderate“Many care visits did not have travel time between them which meant staff were allocated to start their next care visit at the time the previous visit ended.”
incident learning
3 findings
critical“One person's records for August 2020 showed that they had fallen or had seizures three times in the month. No accident or incident forms had been completed.”
critical“An accident did occur at a person's home which resulted in an injury. Staff had not appropriately recorded the accident on an accident form or within the person's daily records.”
moderate“No recording documentation was in place for staff to record incidents to enable the registered manager to monitor and check for increased risk and changes in behaviour.”
person centred care
3 findings
moderate“Assessments undertaken with people before they received a service had not always been used to develop a care plan...staff had no guidance about how to meet people's assessed needs.”
moderate“Life histories were not in place within many people's care plans and no information was recorded to show what and who was important to them to give a holistic view of the person.”
moderate“Life histories were not included in people's care plans and no information recorded to show what and who was important to them to give a holistic view of the person.”
safeguarding
2 findings
critical“CQC had not received a notification of alleged abuse in relation to this incident [missed medicines safeguarding concern].”
critical“Staff had not always been recruited safely to ensure they were suitable to work with people. The provider had not carried out sufficient checks to explore staff members' employment history.”
staff training
2 findings
critical“Staff had not completed epilepsy awareness training, diabetes awareness, stroke awareness or catheter care training despite providing care and support for people with these conditions.”
critical“None of the staff employed by Boldglen Limited Medway and Swale were trained to be able to provide stoma training to others.”
staff competency
1 finding
critical“Staff were not recruited safely...All three showed gaps in staff employment history. These gaps had not been addressed and recorded.”
consent capacity
1 finding
critical“Staff responsible for carrying out assessments had no awareness of the MCA process to ensure that decision making was decision specific for each person.”