critical“We found gaps on their Medicines Administration Record (MAR) sheets... MAR sheets were not being audited. This put people at risk of harm.”
critical“Medicines were not always managed appropriately...no record in the care plan of why this was being administered...no medicines audits completed or spot checks made.”
incident learning
2 findings
critical“The service had not recorded this as an accident or an incident though it clearly was... little opportunity for learning from incidents or accidents.”
moderate“Staff seemed unaware of any changes made due to incidents or accidents...one staff member told us, 'Not really,' [when asked if lessons had been learned].”
governance
2 findings
critical“There were no audits or quality checks of care plans or staff files... quality assurance systems or processes which may have identified the issues we found.”
moderate“At the time of the inspection the registered manager told us they were not completing any audits or spot checks.”
staff training
2 findings
moderate“Staff did not receive supervision regularly. Only one staff member had received supervision and that had been seven months before the inspection.”
moderate“Staff inductions were not recorded in employee's files...No staff had received appraisals as the service had been operation for less than one year.”
supervision appraisal
2 findings
moderate“Three of the four staff files we looked at contained no spot checks, neither did they contain supervisions.”
moderate“One staff member told us, 'No – I didn't get any [supervision].' ...one staff had only been supervised once in six months.”
record keeping
2 findings
moderate“The service user guide was out of date. It had not been updated since the previous registered manager had left the service.”
critical“One risk assessment had not been updated when a person's circumstances had changed requiring them to have their medicines administered by the service.”
safeguarding
1 finding
critical“Since the previous inspection the service had not sent any safeguarding alerts to the host local authority.”
staff competency
1 finding
critical“One employee did not have a Disclosure and Barring Service (DBS) check... gaps in people's employment history, references missing from staff.”
communication with families
1 finding
moderate“We found a person's daily log where staff had stated a person should see a doctor, but no action had been taken to follow this up.”
care planning
1 finding
critical“Risk assessments were scored to indicate the level of risk...however, none of the risk assessments we saw were scored.”
staffing levels
1 finding
moderate“This lack of employees meant that people did not always receive the care they wanted at a time that had been agreed.”
leadership
1 finding
moderate“The registered manager did not feel supported in their role...they felt they could not complete their responsibilities as they were often required to take on caring responsibilities.”
missed or late visits
1 finding
minor“One relative told us, 'If they're ever going to be late, [staff member] rings me to inform me so I can ring my [relative].'”