moderate“Topical cream charts for 4 people had not all been updated following changes.”
moderate“Staff had recently started leaving a person's morning medicines out for them to take as per their verbal instructions. The registered manager understood a written risk assessment should have been in place prior to this change.”
critical“A member of staff had administered people's medicines prior to the completion of their medicines competency assessment.”
critical“Staff had not always documented the administration of a person's medicine on their medicine administration record (MAR). One staff member told us, 'I was a bit relaxed'.”
critical“Two people were prescribed medicines to be administered 'as needed.' There was a lack of written guidance for staff to enable them to understand when the person might require the medication.”
minor“Staff recorded the administration of 'over the counter' topical creams for two of the seven people in their daily notes but not on their MAR.”
moderate“Only one staff out of five had this training completed at the time of the inspection. Therefore, the provider did not adhere to medicine policies and procedures fully.”
critical“The provider had not completed a full assessment of people's medicine support needs as required by national guidance and their medicines policy.”
governance
7 findings
minor“The registered manager told us about their progress with actions, but needed to record when they were completed.”
moderate“Further time was required, to demonstrate the medicines audit process was fully robust and embedded.”
minor“The provider's last CQC report was not displayed either in their office or on their website at the start of the site visit as legally required.”
critical“The registered manager had failed to inform CQC as required of a person who had sustained an ungradable pressure ulcer in May 2022.”
critical“The provider had failed to notify CQC of two recent notifiable incidents at the time they occurred as legally required.”
moderate“They were not able to evidence to us the work they have carried out to ensure their service was adequate and of good quality at all times.”
critical“None of the 20 identified actions on the audit had been signed off as complete. The provider was not able to demonstrate they would be able to complete all remaining outstanding actions.”
record keeping
6 findings
minor“Occasionally they referenced an incorrect pronoun for the person.”
moderate“Some people's care records were inaccurate, lacked dates and attention to detail and contained conflicting information about their care.”
moderate“Daily care records for two people were incomplete and not all daily records for a third person were readily available.”
moderate“One person's records contained the name of a person who was not their relative and another person's risk assessment noted their gender incorrectly.”
critical“None of the staff had any health check completed to ensure they were fit to carry out their role. All staff had gaps in their employment history which had not been explored.”
critical“The failure to maintain securely an accurate, complete, up to date and contemporaneous record for each person was a breach of Regulation 17.”
infection control
3 findings
minor“We were not totally assured that the provider's infection prevention and control policy was up to date.”
critical“A person's risk assessment noted PPE was to be worn at all times during personal care. The person's carer told us, they had 'no gloves and aprons'.”
moderate“Two people told us staff washed their hands after they had removed their gloves but not before they put them on.”
communication with families
3 findings
minor“A relative felt communications from the office could be clearer sometimes.”
moderate“Some relatives reported they were not always aware of who was replacing their loved one's live-in carer when they took a break or if they planned to return, which caused anxiety.”
moderate“The person's relatives had told us they were extremely unhappy about the care provided. The feedback form did not provide an up to date record of their views.”
missed or late visits
3 findings
critical“over a 45 day period I have had 28 missed visits for two carers [only one came] and two missed visits for two carers [no one came at all]”
critical“The provider did not have effective systems to mitigate the risk of missed calls. Staff had failed to arrive for a planned care call and they were not informed.”
moderate“We saw on the 07 April 2019 there had been 16 late call alerts. There were five late calls by 11:10 on 8 April 2019.”
staffing levels
3 findings
critical“The failure to deploy sufficient numbers of staff to meet people's care needs as commissioned was a breach of regulation 18(1)”
moderate“One person told us, on occasions only one care staff was provided instead of two as commissioned. They had been assessed as requiring two staff to provide their care.”
critical“The provider did not follow their recruitment process to ensure they employ fit and appropriate staff.”
staff competency
3 findings
critical“Three care staff spoken with were not familiar with the provider's safeguarding policy and relevant information, such as the need to record any damage to service users skin on a body map.”
moderate“A relative told us the staff member providing end of life care to their loved one lacked sufficient knowledge. When we spoke with them they could not recall this training.”
critical“A staff member's file reviewed lacked both the date they completed full-time education and a full employment history dating back to when they had completed full time education as legally required.”
supervision appraisal
3 findings
moderate“Two staff had no evidence of supervision or spot checks and two staff had evidence of one supervision each on the day they commenced work.”
moderate“People were supported by staff who did not have regular supervisions (one to one meetings) with their line manager...they could not evidence they recorded these conversations.”
minor“The provider had since December 2018 commenced one to one staff supervisions...This process was still new and needed to be fully embedded and completed three monthly.”
care planning
3 findings
critical“Five relatives said the person either lacked a care plan or it was incorrect… 'There is no care plan in the house.'”
moderate“Records confirmed one person was living with dementia, but their care plan lacked sufficient detail about how staff should meet their needs for social stimulation.”
moderate“People's electronic care plans were not always fully person centred or individualised. Records showed three people enjoyed identical activities.”
safeguarding
2 findings
critical“Two of them both reported their relatives had been 'force fed' by staff. CQC reported these incidents to the relevant local safeguarding authorities.”
critical“They were not able to demonstrate they had effectively addressed all of the concerns which arose from one safeguarding alert. This meant one of the issues carried on.”
staff training
2 findings
moderate“some haven't known how to turn on the oven… a carer did not know how to apply their continence pad and they had to instruct them.”
moderate“Not all staff had medicine training and dementia care training and there was no information to indicate they were booked to attend it.”
consent capacity
2 findings
critical“The MCA form staff used to assess if people lacked capacity, was incorrect. It made reference to multiple decisions, rather than being decision specific.”
moderate“There was a lack of written evidence to demonstrate people had signed them. The provider had identified this issue in their audit of 12 January 2019.”
incident learning
2 findings
critical“Staff did not all understand their responsibility to raise concerns, record safety incidents and near misses… neither of these injuries were logged.”
minor“The registered manager did not demonstrate a good understanding of when the commission need to be notified.”
complaints handling
2 findings
moderate“I have given up trying to complain, nothing happens, I ring up but you are just ignored… if you ring them nothing much changes.”
minor“The provider was not able to demonstrate there was an effective process for documenting people's verbal complaints and the actions taken.”
person centred care
1 finding
critical“The failure to ensure people's care plans were personalised to their needs, preferences and interests was a breach of regulation 9.”
leadership
1 finding
critical“The registered manager did not appreciate the extent or depth of the failings and did not have a robust plan to improve the standard of care.”
end of life care
1 finding
moderate“Both people receiving end of life care felt well cared for...however, their care needs in relation to their end of life care had not been documented for staff's reference.”