moderate“there were some inconsistencies in the recording such as gaps being left on the MAR sheets when medication was not required”
moderate“five of the ten MAR looked at did not fully identify when medication commenced or ceased as the dates were missing from the MAR sheets viewed”
record keeping
1 finding
minor“whilst the quality assurance system was adequate we noted that it would benefit from additional information being recorded in a more consistent format”
staffing levels
1 finding
critical“references on nine of the files viewed were not provided from the person's previous employer...recruitment process was poor and there was considerable risk to people”
governance
1 finding
critical“A warning notice for regulation 17 was issued to the provider...provider did not have systems and processes in place to assess, monitor and improve the quality, safety of the service.”
supervision appraisal
1 finding
critical“Two senior staff spoken with told us they had never received supervision or support meetings. One carer said 'Supervisions, they are non-existent'”
staff training
1 finding
moderate“not all established staff had been provided with some of the refresher training...refresher training rota had not been updated due to an administrative error”
leadership
1 finding
moderate“registered manager was responsible for managing two separate agencies without being able to delegate some of her duties...unable to ensure the service was run in the best interests”
incident learning
1 finding
moderate“completion of these audit checks was not recorded at all. This oversight had increased the risk that problems might not be quickly identified and resolved.”
complaints handling
1 finding
minor“One person said they had made a complaint about times of calls but said 'they did nothing about it'...Not everybody felt able to make a complaint.”
missed or late visits
1 finding
minor“any missed calls were identified by word of mouth...One person told us that their carer had not arrived for the tea time call and no one had contacted her”