moderate“the provider's audits had not ensured a person's fluid balance and their urine presentation, was consistently recorded as per guidance in their care plan and risk assessment.”
moderate“Care records contained information that was not always up to date. One person's care plan contained information about a pressure sore that was no longer correct.”
critical“The provider failed to maintain accurate and complete care plans, risk assessments and daily records.”
critical“Records reviewed were not always complete or legible. The provider did not have effective systems and processes in place to identify this”
moderate“Records relating to former employees and the planning and delivery of care had not been stored securely and in line with legislation and guidance”
governance
5 findings
minor“systems that monitored reviews of care plans and other care documents, had been consistently dated when completed.”
critical“This is the third consecutive inspection where the provider has failed to meet the regulations. There have been repeated breaches in relation to safe care and treatment, good governance and staffing.”
critical“The provider did not have robust systems in place to effectively monitor and improve the quality and safety of the service.”
critical“We requested audits but the provider failed to produce any completed audits during our inspection.”
critical“there was no record of staff testing... The provider did not have any system in place to monitor calls.”
medication management
5 findings
moderate“Medication care plans were not always detailed. People's preferred method of taking their medicine or confirmation of their level of compliance when taking their medicine was not recorded.”
critical“Medicines were not always managed safely. Medicines used to thin the blood, to prevent clots, were not always accompanied by a risk assessment”
critical“'As and when required' (PRN) protocols did not always contain enough detail. This put people at risk of receiving the wrong dose of medicines.”
critical“People were at risk of not receiving medication as prescribed as there was no record of whether the medicine was given or refused. Medication administration records (MAR) also did not include the name or dose”
critical“it was not possible for the care workers to reliably know when the patch was to be removed and a new one applied.”
care planning
4 findings
critical“Risks of supporting people to move using equipment were not always assessed and staff were not guided as to how to support them safely.”
moderate“We saw a care plan for a person who required catheter care, which did not direct staff how to manage the person's catheter.”
critical“one person had a catheter but there was no guidance for staff to follow to ensure they were supporting them safely and mitigating risks.”
critical“Another person's risk of developing skin damage was not identified in care plans and so staff did not have guidance to follow to ensure this was monitored.”
missed or late visits
4 findings
moderate“They are certainly not always on time by any means and they don't let me know if they're going to be late.”
moderate“The care is brilliant, but the timings is not brilliant, they are sometimes late.”
critical“we saw evidence staff attended calls up to three hours earlier than the agreed time. This meant some people were supported in the morning as early as five o clock”
critical“the impact of this for one person was that they are missing meals, as the morning call was so late...as a result, they would not eat lunch and have lost weight.”
infection control
4 findings
moderate“People and relatives told us face masks were not always worn by staff. One person told us '[Staff] come in with a mask but take it off.'”
moderate“The provider did not always ensure personal protective equipment (PPE) was being used effectively and safely by their staff.”
critical“The provider's infection prevention and control (IPC) policy had not been reviewed to include COVID-19.”
moderate“One person told us their care worker was not wearing masks from "when things relaxed a bit this year".”
staff training
3 findings
minor“3 staff who were required to complete stoma and catheter care. The management team told us these staff were not required to provide this training.”
critical“Only 2 staff members had specific training in health conditions that people who were being supported had such as; catheter or stoma care.”
critical“Staff were not up to date with Basic Life Support (BLS) training. This put people at risk of harm should they require BLS care when they are being supported by care workers.”
communication with families
3 findings
minor“some staff felt further improvements were required such as an increase in face to face training and in some areas of communication.”
moderate“The office is not good at communicating with client or staff.”
minor“The service did not have systems in place to formally ask for people's views on the service such as customer satisfaction surveys.”
staffing levels
3 findings
critical“The schedule for people's care calls often overlapped. One person was scheduled a 45 minute care call at 8.30am, the same staff member was expected at another person's home at 8.45am.”
critical“There were not always enough staff. Staff told us they worked multiple days in a row without a day off”
critical“There was not sufficient staff who had been appropriately trained employed at the service, this put people at risk of harm.”
incident learning
3 findings
critical“The majority of the issues identified during the inspection were similar to issues we identified at the previous inspection. Quality assurance processes had failed to ensure that improvements made had been sustained.”
moderate“Lessons had not always been learnt. Since the last inspection, there remained areas of improvement which had not been addressed such as PRN protocols”
moderate“Lessons had not always been learnt when things went wrong. Complaints were not logged in an effective way.”
safeguarding
3 findings
critical“Three staff had not been subject to Disclosure and Barring Service (DBS) checks prior to providing people's care.”
critical“another safeguarding incident we and the provider had been notified of by a member of the public, was not recorded in the safeguarding log.”
moderate“One staff member was not aware what whistleblowing meant or what the whistleblowing policy and procedures was.”
consent capacity
2 findings
critical“Where people were known to lack capacity to make certain decisions the provider had failed to assess their decision-making ability.”
critical“one service user's records said they could not make any decisions, but their consent to care had not been assessed in line with the Mental Capacity Act (MCA) 2005.”
leadership
2 findings
moderate“The registered manager lacked oversight of the rota for care workers.”
critical“the provider, who is also the registered manager, refused to attend the service on day one of the inspection or to facilitate access to records on day one”
staff competency
1 finding
moderate“The staff member completing the checks had not received training in medicines, according to the training matrix. This meant staff competency in medicines may not be accurately assessed.”
complaints handling
1 finding
critical“Whilst complaints were recorded in a logbook, there was no action as a result of this, meaning lessons were unlikely to have been learnt.”
other
1 finding
critical“we reviewed four people's staff files and there was appropraite references completed in just one staff file.”