critical“we found all call records reviewed to contain inaccuracies. For example, we saw that a person had received calls of 0 minutes and 2 minutes on numerous occasions over a period of 3 months.”
moderate“Audits undertaken had not identified or effectively prioritised where improvements needed to be made or improvements had not been made in a timely manner.”
minor“Audits were not always carried out regularly or comprehensively. This meant that the effectiveness of the quality assurance of the service was inconsistent”
moderate“There were no audits or quality assurance checks available for us to view.”
critical“The providers systems had not been effective at identifying risks and improving the quality of the service. This is a breach of regulation 17 'Good governance'”
record keeping
3 findings
critical“some topical ointments did not have appropriate body-maps within the Electronic Care Records (ECR). Staff told us that they read instructions for application from the package”
moderate“Paperwork which was in place was often left blank, so that any issues could not be followed up to people's satisfaction.”
minor“We saw that not all complaints had been captured in the providers records.”
medication management
2 findings
critical“poor record keeping meant that staff who were not familiar with the person receiving care would not be able to gain easy access to records of how to apply ointments and creams.”
moderate“Medicines were not recorded in a way that clearly showed an audit trail of what had been administered. There was no number available to show the initial amount of medicines.”
care planning
2 findings
moderate“People's Electronic Care Records (ECR) had limited information about peoples personalised care needs, life history and things that were important to them.”
moderate“People's care records had limited information about peoples personalised care needs, life history and things that were important to them.”
person centred care
2 findings
moderate“People's ECR contained minimal information about people's communication needs. This meant that staff did not have access to relevant information and so could miss verbal and non-verbal cues.”
moderate“People's personalised care needs had not been asked for and recorded to ensure they received consistent care from staff.”
incident learning
2 findings
critical“No notifications had been sent to us, despite incidents occurring, including one within the previous six months where a person was found bruised following a fall.”
moderate“These had not been fully implemented to show when things had not gone to plan, the lessons that had been learnt from this to improve the service.”
staffing levels
2 findings
moderate“Some carers can turn up very late and weekends are worst. There are enough staff during the week, but the weekends can be a nightmare.”
critical“Staff who had left and re-joined the agency had commenced care calls before all the necessary pre-employment checks had been completed, without a recorded risk assessment in place.”
safeguarding
1 finding
moderate“Staff were very unsure about whistleblowing and didn't fully understand the concept. I am not sure who I would go to above the manager.”
complaints handling
1 finding
moderate“We did not see any written complaints in files although the registered manager agreed that complaints had been made and dealt with. There were no audits available.”
leadership
1 finding
moderate“I am a great supporter of Crestar and the manager, but I have concerns that he just isn't running the place right.”
supervision appraisal
1 finding
moderate“Staff did not receive regular supervision. The provider told us in their PIR that this would be provided at least four times a year, however staff were receiving supervision...less frequently.”