moderate“Care planning information did not always reflect people's individual needs. One person had a catheter but there was no guidance for staff regarding its management.”
moderate“care plans were not developed where there were needs associated with the person's emotional, health and wellbeing. For example, how staff were to communicate with the person.”
moderate“Care plans were not fully person centred as they did not give staff direction on how people liked their care needs to be met.”
moderate“The risk assessment for two people stated their skin integrity was compromised at times. The actions to take were brief and descriptions on the signs of skin breakdown needed more detail.”
record keeping
4 findings
moderate
“One staff member had written they had identified a sore area of skin. Staff in subsequent visits did not mention the soreness but it was raised again a few days later.”
critical“Records were not always accurate and up to date. Where MAR charts did not have correct directions for administration the audit had not identified the shortfall.”
minor“Some risk assessment action plans lacked person centred care, background history, and guidance on meeting people's needs in their preferred manner.”
moderate“Where people smoked and had paraffin based topical creams risk assessments did not include the measures in place to reduce the potential of fire.”
medication management
3 findings
critical“Some showed handwritten changes to the medicine's prescription, without explanation or the staff member's signature. One person was prescribed paracetamol, but staff had not documented the time they had given it.”
critical“directions for the applications of cream were not clear on the MAR's... the instruction on the MAR for the application of cream was "as directed"”
moderate“Protocols for when required (PRN) medicines and creams were missing and where they were in place, they lacked guidance on administration.”
governance
3 findings
critical“Auditing systems were not always effective in identifying shortfalls and ensuring safety. This placed people at risk of harm. Breach of regulation 17.”
critical“findings of this inspection in relation to the areas identified for improvement were not consistent with audit log.”
moderate“Not all our findings had been identified for improvement within the audits. For example, supervision of staff and medicine systems.”
consent capacity
3 findings
moderate“care records were not clear on who made complex decisions for people that lacked capacity... relative did not have the legal authority to make these decisions.”
critical“Staff told us that bed sides were used for some people who lacked capacity to make decisions. These staff were not aware of having authorisation to deprive people of their liberty.”
moderate“Mental capacity assessments were not completed before some best interest decisions such as for people who had a sensor in place. Where key safes were used mental capacity assessments were not completed.”
missed or late visits
2 findings
moderate“One person who had a 30 minute allocation, but their visit was recorded as '17.00 – 17.16'. Two relatives told us shortened visits was a regular occurrence.”
moderate“since January 2018 there were seven missed visits... missed visits were generally due to staff not looking at the rotas provided.”
incident learning
2 findings
moderate“Daily reports were not detailed on the repositioning changes that took place on each visit. This meant risks were not assessed and monitored.”
minor“There were no recorded accidents or incidents since 2017. The accident and emergency procedure were updated in 2017.”
supervision appraisal
2 findings
moderate“Staff told us one to one meetings with their line manager to discuss concerns, training needs and personal development was not taking place.”
minor“Another member of staff said there were spot checks, an annual appraisal but one to one supervision had not occurred.”
person centred care
1 finding
moderate“Daily records were task orientated and not person centred. Staff had written entries such as, 'Showered, dried and dressed'.”
other
1 finding
critical“Lack of guidance for staff to manage risks safely was identified at the last three inspections in July 2019, May 2018 and February 2017.”
safeguarding
1 finding
minor“two staff were not clear on the types of abuse they knew to report their concerns.”
staffing levels
1 finding
moderate“Four visits were organised to take place between 12 noon and 1:15pm. This member of staff had to complete 25 visits in their eight hour shift.”