critical“Two of the three care plans reviewed were for people who were regarded as end of life. However, the care plans made no reference to any end of life plans, preferences or contact details.”
moderate“A care file of a person who had started using the service two weeks ago did not contain any risk assessments despite the person receiving catheter care.”
moderate“Care plans were not person centred and did not always contain the level of detail staff needed to make sure they delivered the care and support people needed.”
moderate“Care files did not reflect a robust approach to gaining people's views about the care and support they would like to receive as they approached the end of their life.”
medication management
3 findings
critical
“Some medicines did not specify the dose required on the MARs. Additional medication was handwritten on the MARs but these were not signed by staff or signed by a second member of staff.”
critical“One person was receiving their medicines covertly...there was no evidence a pharmacist had been involved in this process...no evidence to show guidance had been sought from a pharmacist.”
critical“patch was recorded as administered twice...MAR had been repeated with different signatures of administration on both. Breach of Regulation 12 (g).”
record keeping
3 findings
moderate“Accurate and contemporaneous records were not kept for each service user. Care records did not clearly show the number of calls a person required, the purpose of the call or the call times.”
moderate“one file we looked at did not contain any risk assessments in relation to the person being blind and hard of hearing.”
minor“the list of medicines one person was taking had not been updated on this document.”
end of life care
3 findings
moderate“Two of the three care plans reviewed were for people who were regarded as end of life. However, the care plans made no reference to any end of life plans, preferences or contact details.”
moderate“care records for a person diagnosed with a terminal illness did not include a 'Do Not Attempt Resuscitation' (DNAR) order.”
moderate“Training records showed less than a third of care staff had received training in providing end of life support.”
governance
2 findings
critical“The provider did not have adequate systems and processes for assessing and monitoring the quality of the service...breach of Regulation 17 of the Health and Social Care Act 2008.”
moderate“accidents and incident information was not collated and analysed to enable the registered manager to identify and address any emerging trends.”
incident learning
2 findings
moderate“There was no system in place to monitor for patterns and trends over a period of time...no detailed analysis undertaken for patterns and trends over a set time period.”
moderate“there was no analysis of complaints and concerns or call performance...MARs audits had failed to identify issues such as the ones described.”
complaints handling
2 findings
minor“I have made my views known but promises made to rectify the situation has not materialised.”
moderate“the provider had not obtained confirmation from the complainant that they understood and were satisfied with the outcome of their complaint.”
supervision appraisal
1 finding
moderate“There was no supervision matrix in place to show staff had planned supervisions scheduled. We saw only a limited amount of staff had received formal supervisions in the last five months.”
safeguarding
1 finding
critical“incidents relating to suspected emotional and financial abuse had not been notified to the CQC...breach of Regulation 18.”
missed or late visits
1 finding
moderate“Seven people we spoke with told us they had experienced missed calls...registered manager told us they didn't maintain a missed call log.”
communication with families
1 finding
moderate“changes to the needs of people who used the service were not always communicated to staff...staff had turned up at people's houses when the office had been informed the person was in hospital.”
infection control
1 finding
minor“they shove wet nappies and pads in the nearest bin even if it is overflowing...I have to tell them to wash their hands before doing my meals.”
consent capacity
1 finding
minor“consent on one occasion had been sought from people's relatives even though the person had capacity to do this.”