critical“Medicines were not always safely managed. People did not always receive their medicines as prescribed which meant they were at risk of harm.”
critical“not all staff had up to date medicines training and/or had their competency to administer medicines assessed in line with National Institute of Clinical Excellence (NICE) guidance.”
critical“one person's MAR chart containing conflicting medicines information. The instructions were to 'take 3 tablets twice a day', however the MAR chart records 'take 1 tablet in the morning and take 2 tablets at night.'”
critical“We analysed three months of care calls on the ECM system prior to the inspection. We identified there were 512 missed calls.”
critical“We reviewed Medicine Administration Records (MAR) for three people...and found a number of gaps on each of the MAR charts where staff had failed to sign.”
safeguarding
4 findings
critical“Potential safeguarding concerns were not always reported to CQC. There was not a robust system in place to record accidents and incidents.”
critical“a safeguarding concern that took place in November 2023. However, the provider did inform CQC within our guidance… We were informed of this concern not until 14 days after the incident occurred.”
critical“There was no effective system in place to safeguard people appropriately and manage concerns of abuse. There was no safeguarding file or system in place.”
critical“A potential safeguarding had not been reported to CQC until March 2023, a month after the incident and following the demise of the person involved.”
care planning
3 findings
critical“People's care plans only consisted of a list of tasks staff were required to carry out. Therefore, people's needs were not always accurately assessed.”
critical“People's care plans were not always person-centred and contained minimal information. Records did not always detail how people's specific health needs affected them.”
critical“Some people's care plans were not always person-centred and contained minimal information...no guidance for staff on how to support people with their individual needs effectively.”
staffing levels
3 findings
critical“There were not enough staff deployed effectively to meet people's needs in a timely manner.”
moderate“persistent issue of dual location visits, this meant that staff were logged as being at two places at the same time. The provider had not identified this issue.”
critical“Staff were not effectively deployed to meet people's needs in a timely manner. The provider failed to ensure that they had an effective call monitoring system (ECM) in place.”
staff training
3 findings
critical“The provider could not evidence that staff who worked independently had received PEG training to meet service users' needs safely.”
critical“Staff supporting people living with Parkinsons Disease, continence care, insulin-controlled diabetes, and using specialist equipment had not received adequate training in these areas.”
critical“Two staff members had not completed any mandatory training since they joined the service. Three staff members had not completed all mandatory training since joining.”
supervision appraisal
3 findings
moderate“Out of the 14 staff files we reviewed we saw that seven staff members did not have any supervisions within the last year.”
moderate“The supervision policy did not stipulate how frequently staff would be supported with supervisions. The frequency of supervision was variable. Some staff had more supervisions than others.”
moderate“Three staff members had not been supported with regular supervisions since our last inspection in August 2022.”
governance
3 findings
critical“Governance and audit systems were not effective at identifying and reducing risks to people's safety. There was a lack of effective leadership and oversight.”
critical“since our last inspection in April 2023, there were no staff file or ECM audits carried out until November 2023. This audit did not identify the issues we found at this inspection.”
critical“Since our last inspection in August 2022, there were no regular medicine audits carried out for all people using the service.”
incident learning
3 findings
moderate“The provider had failed to carry out analysis of any trends to identify areas where lessons could be learnt and disseminated to staff.”
moderate“the provider failed to carry out analysis of accidents and incidents to identify trends and where lessons learnt were disseminated to staff.”
moderate“The provider failed to carry out analysis of accidents and incidents to identify trends and where lessons learnt were disseminated to staff.”
record keeping
3 findings
moderate“There were no audits carried out in relation to care plan audits, staff files, daily notes and communication books, to identify shortfalls.”
moderate“The provider had 3 versions of the training matrix; therefore, the provider could not be assured that all staff training was up to date.”
moderate“Care records were not always regularly reviewed. Support plans were not always signed either by people or their relatives consenting to their care.”
person centred care
3 findings
moderate“People and/or their relatives were not supported to be involved in decisions about their care. Care records did not capture preferences about culture and religion.”
critical“Care plans for people living with specific health conditions encouraged staff to support people in a way that placed them at risk of potential harm and without input from healthcare professionals.”
moderate“People or their relatives were not always supported to be involved in decisions about their care...care records did not always document if people were able to choose what they wanted to wear.”
cultural competency
3 findings
minor“People's cultural needs had not always been explored and documented in people's care plans, this included the food they liked and the language they communicated in.”
minor“Care plans documented 'Be aware of cultural/religious practices that may affect personal care' but did not specify what these were.”
minor“People's cultural needs had not always been explored and clearly documented in people's support plans.”
consent capacity
3 findings
minor“People's consent to care and support was not always documented.”
critical“The provider's medicine policy did not mention covert medicines and did not have clear procedures for giving medicines covertly.”
moderate“Support plans were not always signed either by people or their relatives consenting to their care. Staff had not always signed and/or dated support plans.”
leadership
3 findings
critical“The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”
critical“The registered manager was unaware of the issues identified during the inspection, regarding the lack of risk assessments, poor medicines administration, poor recruitment processes.”
critical“The registered manager did not adequately understand their role, regulatory requirements and lacked leadership and oversight of the service.”
missed or late visits
2 findings
critical“People and their relatives told us their visits were often late and they were not informed if there were going to be any changes.”
critical“512 missed calls. Punctuality was poor, with only 60% of calls delivered within 15 minutes of the planned time and 20% of calls were more than 45 minutes late.”
complaints handling
2 findings
moderate“Not all complaints, including verbal, were logged and investigated in line with the provider's complaints procedure.”
moderate“Complaints were discussed with some people via WhatsApp message, instead of adhering to the provider's internal complaints policy.”
end of life care
2 findings
minor“Care records did not contain advance decisions about people's choices about the end of their life. The registered manager told us they had not explored this.”
moderate“Care records did not always contain advance decisions about people's choices about how they wished to be supported at the end of their lives.”
communication with families
2 findings
moderate“Relatives told us that communication with the management team was poor. One relative said, 'I have to communicate with the carers as management don't contact me.'”
moderate“People or their relatives had little involvement in the planning or review of their care. One relative told us, 'I don't know if [family member] has a care plan.'”
staff competency
2 findings
critical“staff 'are to use breakaway strategies in the unlikely event the person holds onto carers clothes'… Staff told us they did not know to do this and had not been trained in breakaway strategies.”
critical“The provider did not follow safe recruitment practices...accepted a basic (not enhanced) DBS check that a staff member had carried out themselves.”
infection control
1 finding
moderate“Infection control was not always appropriately managed. Some people and relatives told us that staff sometimes wore PPE or not at all.”