minor“recent audits of eMAR charts had not identified records had not recorded whether one or two tablet medicines had been given where this was an option”
critical“only four out of the eight electronic medicine administration records (eMARs) seen had evidence this system had been carried out”
moderate“the audit took place on the 25 October 2021 looking at administration records that had been completed between the 1 and 7 of August 2021”
moderate“one person had had their medicines administered too close together on two separate occasions”
critical“One person had paracetamol repeatedly given before the safe four-hour gap. This had already been recognised as a risk by the registered manager but not resolved for the next month.”
critical
“family member should have had twenty three left but there are twenty-four left, they have all been signed for. I have reported that and it isn't the first time”
missed or late visits
5 findings
minor“People told us they still experienced some variations with the timings of their care calls...One person told us they had experienced the occasional missed call.”
moderate“one care staff comes between 7.30 and 8pm. Other care staff come between 9 and 10.30pm and another staff member can come between 10.45 and 11pm”
critical“Three occasions where they haven't arrived at lunch time. I called and they said they were running late – ten to fifteen minutes away. I waited and waited but no one came.”
moderate“Some people told us staff were late, and they were not always contacted by the office.”
moderate“I never get a rota, they come at all different times, late [or] early... sometimes lunch is at 11.30 which is too early”
governance
5 findings
minor“audit process needed further time to fully embed improvements in the service”
critical“Audit processes had not been effective at identifying where statutory notifications had not been submitted to the Care Quality Commission as required.”
critical“audit processes had failed to identify that potential safeguarding incidents had not been referred to the local authority”
critical“We identified 16 notifications had not been made by the registered manager... since this discussion, the registered manager had failed to notify the commission of an additional six incidents.”
moderate“The service does not have registered manager. The current manager is awaiting documentation before she can forward an application to be registered.”
leadership
2 findings
minor“There was no registered manager at the time of our inspection, however the recently appointed manager had begun the process of registration.”
moderate“The previous registered manager had cancelled their registration with CQC in August 2021 and a new registered manager was not in post at the time of this inspection.”
safeguarding
2 findings
critical“a safeguarding referral had not been made when a person had made an allegation of abuse. The provider told us they accepted a safeguarding referral should have been made”
critical“Two people had made allegations that care staff had stolen from them. The registered manager had not made referrals to the police. This left people at ongoing risk of theft.”
incident learning
2 findings
moderate“the provider did not speak with the care staff who could have made the error and the investigation did not conclude with any outcome”
critical“Medicine errors had not been suitably investigated to prevent re-occurrence. There were repeated incidents of staff using medicines from different blister packs.”
record keeping
2 findings
moderate“Daily notes kept by care staff were brief and did not include enough detail on what care was provided. The poor record keeping meant other staff and the management team would be unable to identify changes.”
moderate“medicine was given but this had not been recorded on the appropriate charts”
complaints handling
2 findings
moderate“The service complaints policy stated that complaints would be responded to in writing within 28 days, there was no evidence that people's complaints had been responded to as the policy required.”
minor“I complained about the medication, they haven't got back to me about it yet”
person centred care
2 findings
moderate“Care plans lacked detailed information about their physical, emotional and mental health needs. These details are needed so staff can provide personalised and responsive care to people.”
minor“"They need to read the notes more, and there's the odd little blip, some carers will forget to [rearrange furniture to assist with [name] mobility."”
care planning
1 finding
critical“Care plans did not provide sufficient or accurate information on people's healthcare needs. Staff had poor quality guidance on how to support people's diabetes needs, skin integrity needs, choking risks.”
staff training
1 finding
moderate“Staff reported that their induction and training was basic and did not provide them with enough skills to safely undertake their role.”
staff competency
1 finding
moderate“The registered manager advised that parts of the competency assessment asked staff if they know current guidance and recording their answer as 'yes' or 'no'. This process does not actively test staff understanding.”
consent capacity
1 finding
moderate“Capacity assessments had not always been completed to assess if the person could make the decision themselves before informing staff to consult the person's next of kin.”
infection control
1 finding
moderate“The service kept no record of which staff had taken tests and the registered manager believed this testing uptake was low. A staff member told us they were unaware that tests were available from the service.”
communication with families
1 finding
minor“"I must admit it [communication] isn't very good, we've left messages but they don't always get back"”
staffing levels
1 finding
minor“they take on too many clients hence everyone can't get lunch at lunchtime, they need to recruit more staff”