critical“one person's medicine record had not been clearly amended to show a change in the strength of tablets supplied. A second record showed duplicate entries for administration of the same medicine over two days.”
critical“medicines were not being managed safely. Record keeping was inconsistent, including completion of MAR and records of people's prescribed medicines, and some people's medicines had not been given timely”
critical“on some occasions staff had arrived within three hours to administer the medication again”
critical“Some people's MAR had unexplained gaps, making it difficult to establish if people had received their medication as prescribed.”
record keeping
3 findings
critical
“Record keeping relating to medicines management was not robust... breach of regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“Medicines Administration Records (MAR) were not always clear or completed fully. Missing signatures meant it was not clear whether people had received their medicines.”
moderate“system did not show what time staff had arrived and left and in others, staff had failed to log in and out at all”
governance
3 findings
critical“Regular medicines audits were completed but these had not been effective in identifying the issues found on our inspection. We have identified issues with aspects of medicines management at the last 3 inspections.”
critical“Systems and processes to monitor the safety and quality of service provision, identify issues and ensure actions and regulatory requirements were addressed timely, were not robust or fully embedded.”
critical“Quality monitoring systems were not robust. This placed people at the risk of harm. This was a breach of regulation 17 (Good Governance)”
missed or late visits
2 findings
critical“Timekeeping used to be okay, but not now, can be 40 minutes to an hour late. Last time this was discussed with the office, carers still arrived late the next day.”
critical“missed visits/near misses log held by the service which showed 11 had occurred in 2021, some of which had impacted on people's care”
leadership
2 findings
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
moderate“the service had changed offices, but had not registered the new location with CQC before moving.”
care planning
2 findings
moderate“these did not always clearly explain what the risks were, how they impacted on the person's safety and what control measures were in place to minimise each risk.”
critical“their care plan did not contain any information for staff to follow about this and a choking risk assessment had not been completed.”
other
1 finding
moderate“The provider agreed at the last two inspections to ensure de-registration forms were submitted for a previous manager... At the time of this inspection, these forms had still not been submitted.”
person centred care
1 finding
critical“The completion of people's care visits was not always in line with the agreed times as stated on their assessment and care plan. This is a breach of regulation 9 (Person centred care)”
communication with families
1 finding
moderate“One relative was unhappy the care plan had recently been updated without either them or their family member being consulted or informed.”
cultural competency
1 finding
moderate“some people and relatives we spoke with raised concerns about some carers not speaking or having limited English and the impact this had on effective communication during care visits.”
infection control
1 finding
critical“Odd staff are still not coming masked-up and we are sure some are using the same PPE for personal care and feeding.”
staff training
1 finding
moderate“We saw staff had not completed restraint training and recommend this is undertaken.”
safeguarding
1 finding
critical“We had not been notified about a safeguarding allegation of financial abuse that had occurred.”
staff competency
1 finding
critical“they did not always cover staff to work with children”