critical“PRN protocols were not in place where required for 5 people. The provider did not have a system in place for staff to record and monitor 4-hour gaps required between administration of paracetamols.”
critical“Gaps and inconsistencies in the recording meant the registered provider could not evidence people received their medicines as prescribed.”
critical“MARs did not indicate where medicines were prescribed as and when required (PRN) and the dose which should be offered. We saw there were no completed PRN protocols in place.”
minor“We did find one MAR chart which had not been consistently completed.”
governance
3 findings
critical
“The provider did not have effective audits in place to monitor and review the effectiveness or the safety of the service. We identified shortfalls in medicines, calls times, record keeping and training.”
critical“These systems were not effective in identifying some of the areas of concern we found during this inspection as they had either not been recognised or not sufficiently responded to.”
moderate“The management team were using a social media service to communicate messages containing sensitive information...had not complied with the Data Protection Act (1998).”
record keeping
3 findings
moderate“Provider audits were not effective and failed to identify any of the issues we found on inspection.”
moderate“Daily notes were recorded in hard back A4 notebooks...We looked at one record and saw it contained seven months of information before it had been returned to the office.”
minor“We did note there was no provision on the interview record to demonstrate any 'gaps' in employment had been explored.”
incident learning
2 findings
moderate“We were not assured the system for learning lessons were effective because audits had not consistently highlighted where improvements were needed.”
moderate“They made us aware of nine deaths which were expected. The nominated individual said, 'We've not reported them because they were expected deaths.'”
care planning
1 finding
critical“5 lacked specific guidance on how staff should provide person centred care in relation to people's health risks. For example, there was a lack of information for staff on how to manage people with epilepsy.”
staff training
1 finding
critical“Most staff did not have epilepsy, diabetes or stoma care training, despite providing care to people with these conditions.”
missed or late visits
1 finding
critical“We saw examples of staff staying between 15 and 25 minutes for visits which were scheduled for 30 minutes.”
supervision appraisal
1 finding
minor“Staff were supported by the registered manager and received formal supervision where they could discuss their ongoing development needs, although these needed to be more regular.”