minor“Staff do not always arrive on time and carers are not always consistent. We have had some issues with timings.”
moderate“I have had 3 late calls recently, 1 day the carer did not come until 11pm. I ring the office up a lot”
moderate“One person said, "My care worker didn't come until 10pm yesterday and I don't know whether to take my pills or not."”
record keeping
2 findings
moderate“some had no date of completion so it was difficult to see when they were completed and how often they would be reviewed.”
moderate
“Accidents and incident forms were in place; however, these were not always completed in full. For example, time and dates were missing, and information regarding the action taken and outcome for people was not always recorded.”
care planning
2 findings
moderate“People's care plans contained basic information on how to provide care and support to people.”
critical“risks associated with people's catheter care, diabetes and people who were prescribed anticoagulant (blood thinning) medicines. Staff did not have up to date information about these risks and how to mitigate them”
governance
2 findings
minor“only 48 surveys were sent and of those sent 30 replies were received missing an opportunity to capture all feedback from people”
critical“we identified 6 occasions where the registered manager had notified the local authority of incidents but had failed to notify CQC and 1 occasion whereby the local authority had not been notified of an incident relating to a medicine error.”
communication with families
1 finding
moderate“There's no communication with carers unless it's [name of staff]”
medication management
1 finding
critical“staff had either incorrectly used the codes provided at the bottom of the MAR chart or not used them at all, missing signatures and on 1 audited MAR chart we looked at, we found a person had not received their anticoagulant medicine for 5 days”
staffing levels
1 finding
moderate“7% of calls made were short calls, which means less than half the planned time is delivered. Out of 9244 calls made in February 2023 4986 of those had no travel time”
incident learning
1 finding
moderate“accident/ incident overview log, however this failed to capture all of the accidents and incidents we reviewed on the day of the inspection from the services paper data.”
leadership
1 finding
minor“People we spoke to were not aware who the registered manager was and most referred to the care coordinators when asked. People and relatives told us, 'No, I don't know who it is'”
safeguarding
1 finding
critical“incidents we were informed of were not always identified or reported to the appropriate authorities.”
staff competency
1 finding
moderate“1 file contained only 1 reference, 1 file had no interview notes and there were gaps in staff employment history which had not been identified and explored throughout their recruitment process.”