moderate“one risk assessment referred to a family member supporting a person with their medication but the family member had passed away.”
minor“this information could be enhanced to include, for example, symptoms when a person with diabetes had low blood sugars.”
moderate“this information was not included in their risk assessment or care plans and there was no guidance to staff on how they could support the person to manage or prevent these incidents”
moderate“risk assessments...did not always include detailed management plans with guidance for staff on what action to take should the risk occur”
governance
4 findings
critical
“a safeguarding raised by a professional...all appropriate actions had been taken, with the exception of notifying the CQC.”
critical“Collectively, this is a breach of regulation 17 of the Health and Social Care 2008 (Regulated Activities) Regulations 2014 relating to the lack of governance within the service.”
moderate“audits did not identify the shortfalls we found during our inspection. For example, audits of the care records did not identify the issues relating to medication care plans, risk assessments or protocols.”
moderate“medication audits did not identify gaps in medication records and the MAR charts did not utilise the key code appropriately and lacked detail”
record keeping
3 findings
moderate“environmental risk assessments in people's care files were not dated and in one we found some information that was incorrect.”
moderate“risk assessments we looked at were not always specific to people's health related care needs and did not always reflect the information that had been provided in the social worker's initial assessment”
minor“some of the care plans were copied directly from the social care needs assessment and therefore did not reflect the independent assessment facilitated by the provider”
medication management
3 findings
critical“Doesn't always get it through the night when [staff] are here because they don't like giving it”
critical“MAR charts did not utilise the key code appropriately, lacked detail and did not appear to follow protocol in accordance with the person's care needs”
critical“staff were supporting people to take their medications without the relevant training to do so...I had not done anything before hand for about 11 years; I needed a refresher”
consent capacity
2 findings
moderate“their knowledge of DoLS, although slightly improved, required further improvement to ensure the provider understood their legal obligation.”
critical“The provider was unable to articulate their understanding of DoLS and was not aware of their reporting responsibilities.”
leadership
2 findings
moderate“the provider had failed to respond to some areas of our feedback at our last inspection...shortfalls with insufficient and unspecific risk assessments and care plans”
moderate“the service did not always have the required resources readily available to enable them to meet their legal requirements particularly those relating to staff development and training”
safeguarding
1 finding
critical“During our discussions with relatives, we identified a potential safeguarding issue that we referred to the local authority, who are responsible for investigating safeguarding concerns.”
incident learning
1 finding
moderate“daily record logs consistently reported a person to be complaining of persistent pain...This had not been identified by the provider.”
staff training
1 finding
critical“staff had not been trained effectively prior to undertaking home care calls independently...my induction was just shadowing [staff member] for three days”
supervision appraisal
1 finding
moderate“They told us that they did not receive any formal or planned supervision sessions with the registered manager and that the provider does not hold team meetings.”
staff competency
1 finding
moderate“some staff files did not have copies of previous training and staff members were actively providing care without the registered manager being assured of their knowledge and skills”