moderate“there were some gaps in recording by staff on paper medicines administration charts (MAR). The registered manager had identified this issue already and explained the action they were taking”
minor“tightening the oversight of medicines recording and the daily notes written by staff to ensure these were consistently completed accurately and to a good standard”
moderate“previously there were a high number of gaps and omissions on the Medication Administration Records (MAR) when staff had failed to sign the record”
moderate“We looked at the MAR charts for five people using the service and saw there were some gaps and omissions... staff had failed to sign the chart to say they had administered.”
governance
4 findings
minor
“Team meetings involving all staff did not take place regularly but the registered manager planned to reinstate these so staff had opportunities to receive information, share learning”
moderate“these systems had not been effective in resolving issues about people's dissatisfaction about call times and consistency of care staff visits.”
critical“systems were not in place to review key data including incidents and accidents to identify any learning and areas for service improvement.”
critical“potential safeguarding concerns and incidents of concern were not sent to the Care Quality Commission (CQC)”
missed or late visits
4 findings
moderate“The same person doesn't always come and they don't come at the same time. This makes me anxious.”
moderate“one person told us that on one occasion their morning call was late by over an hour. This resulted in them having their medicines later than prescribed.”
moderate“Of the 11 people we spoke with, eight of them raised dissatisfaction with the timings of their calls.”
minor“staff sickness had an impact on the timings of people's calls.”
person centred care
2 findings
moderate“They are supposed to be here for 30 minutes but they only stay for 12 minutes.”
minor“51 people had not been included in this exercise and their views had not been sought.”
leadership
2 findings
moderate“the registered manager only visited the service on average once every two weeks which meant there was no consistent management oversight at the service.”
moderate“the registered provider had not consistently gained and acted upon feedback from people for the purposes of continually evaluating and improving services”
incident learning
2 findings
critical“incidents and potential safeguarding concerns had not been reported to the Care Quality Commission. This meant that incidents of concern had not been reported so they could be responded to appropriately.”
moderate“systems or processes were in place to assess, monitor and improve the quality and safety of the services provided and to mitigate the risks”
medication management
1 finding
moderate“the provider did not maintain a record of medicines administered to people using the service. We have made a recommendation about the recording of medicines.”
complaints handling
1 finding
moderate“My [relative] raised concerns as they were coming later and later at lunchtimes which stopped me going out. It didn't make any difference.”
staff training
1 finding
moderate“one staff member had not completed any mandatory training since 2102 and another since 2013.”
communication with families
1 finding
minor“people were not always informed when staff were running late... 'The staff are not very reliable and they often turn up late. They don't let me know if they are going to be late.'”
care planning
1 finding
minor“Some areas of the care plans would benefit from further detail, for example, when describing peoples dietary likes, the care plans recorded 'various'.”
safeguarding
1 finding
critical“although potential safeguarding concerns were sent to the local authority safeguarding team, the service had failed to notify the Care Quality Commission (CQC) of these.”
staff competency
1 finding
moderate“In four of the files we found gaps in staff employment history, one of which was over six years. We were also unable to find up to date photographs and proof of ID for three staff members.”