moderate“Medicines audits did not identify some people's medicines and Medication Administration records (MARS) had not been reviewed for 3 months.”
critical“for two people we reviewed, we found there were blank gaps on the medicines administration records (MAR)... There were no stock checks of medicines taking place”
critical“One person was prescribed a medicine two times a day. The MAR we reviewed showed that for 24 days they had received this medicine three times a day.”
moderate“When people were prescribed as required medicines there was no guidance in place for staff to follow.”
governance
2 findings
critical
“Systems were either not in place or robust enough to demonstrate effective management to ensure quality and manage risk. This was continued breach of Regulation 17.”
critical“Audit completion was inconsistent... This meant these were not effective in identifying all areas of improvement as they were not consistently completed.”
record keeping
2 findings
critical“Care plans and risk assessments contained conflicting information...the information we reviewed in 1 person's care plan did not reflect the care plan in the person's home.”
moderate“When people were prescribed patches to be administered on their skin, there were no records in place confirming where these patches had been administered.”
safeguarding
2 findings
critical“People were not always kept safe from avoidable harm as measures identified by the safeguarding team had not all been implemented.”
critical“There was an ongoing safeguarding... where one person had received twice the amount of medicines they had required... the provider had not identified this or raised as a safeguarding to the local authority.”
incident learning
2 findings
critical“The provider had received recommendations from the safeguarding team to improve their practice, but these had not been implemented and we found continued concerns during our inspection.”
moderate“there were several incidents where concerns had been raised about staff. Although action had been taken these incidents had continued to reoccur.”
care planning
1 finding
critical“People did not always have risks to their safety assessed and planned for. For example, there were no risks assessment in place for specific health conditions people experienced such as motor neurone disease, autism and epilepsy.”
staffing levels
1 finding
critical“Staff rotas we looked at recorded some staff were attending 2 or more calls at the same time or no staff were assigned to calls at all.”
consent capacity
1 finding
moderate“We found mental capacity assessments and best interest decisions were not carried out for people who may lack capacity. Relatives choices were followed instead.”
staff training
1 finding
moderate“No staff had received learning disability training, which is now a requirement for all services who support people with a learning disability.”
supervision appraisal
1 finding
moderate“Staff had not received support through supervisions or appraisals. However, staff attended team meetings so they could share their views.”
missed or late visits
1 finding
moderate“One person said, 'They aren't usually on time, they can be 30 minutes late.'”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”