critical“Not all staff who administered people's medication had received training or had their competency assessed through direct observation to ensure their practice was safe.”
critical“MAR forms for two people recorded one member of staff had administered two people's medicines on 12 occasions but they were not appropriately trained.”
moderate“A person did not receive their medication as prescribed. The prescriber's instructions stated one of their medicines should be given 30 to 60 minutes prior to food and all other medication.”
moderate“the provider was unable to evidence they had additional documentation in place to help staff know when and how to administer certain medicines such as 'when required' [PRN] protocols.”
governance
4 findings
critical
“Quality assurance and governance arrangements in place were not effective in identifying shortfalls in the service or making the required improvements.”
minor“Improvements were needed to make sure completed audits were less generalised and more focused on individuals who used the service and staff.”
critical“Effective arrangements are not in place to assess and monitor the quality of care provided...This was a continued breach of Regulation 17 [Good governance]...breached for a fifth consecutive time.”
critical“The registered manager did not have systems in place to have effective oversight of the service or assess and monitor the quality of care. This was a continued breach of Regulation 17”
record keeping
3 findings
critical“Unexplained gaps on the MAR forms for two people, giving no indication of whether they had received their medicines or not, and if not, the reason why was not recorded.”
critical“Not all recruitment checks had been completed...only 1 written reference was evident...A written record was not completed or retained for 1 member of staff.”
critical“One person said they had reported an incident of abuse but there was no record of this.”
staff training
3 findings
critical“No records of induction available for eight members of staff. There was no evidence of training for four members of staff.”
moderate“There was no evidence of a completed induction for 1 member of staff who was newly employed at Superhealthcare since our previous inspection in July 2022.”
critical“Two members of staff said their training was out of date. One said, 'Our training has expired. We've done safeguarding training. They [the provider] are getting it sorted now.'”
supervision appraisal
3 findings
moderate“Not all newly appointed staff had received supervision or 'spot visit' checks... One member of staff told us they had not received any supervisions or spot visit checks since commencing in post in December 2021.”
moderate“Where issues were highlighted, no information was recorded detailing how this was to be monitored, followed up and addressed.”
moderate“The registered manager said they were not carrying our formal supervisions or competency checks”
care planning
3 findings
minor“The registered manager should consider assessing people's environmental risks.”
critical“the registered manager had still not put care plans in place for people. However, they had created a 'routine' for staff to follow.”
critical“Risks to peoples' safety and well-being had not been assessed... eight of the 10 people receiving care had risks associated with their health and wellbeing”
staff competency
2 findings
critical“Recruitment practices remained unsafe and lessons had not been learned to make the required improvements. No recruitment files were available for three members of staff.”
critical“the registered manager failed to provide evidence of staff training and competence and stated they had not carried out any competency assessments with staff.”
safeguarding
2 findings
critical“No Disclosure and Barring Service [DBS] checks were completed for these staff... A risk assessment was not completed or considered to assess and manage the risks.”
critical“The provider had failed to record or report the incident which was a breach of regulation 13”
incident learning
2 findings
critical“There was no analysis, follow up, or investigation to identify the potential causes of injuries sustained by people using the service. For example, unexplained bruises identified on body maps.”
critical“Lessons had not been learned since the last inspection. At this inspection we found the registered manager had failed to make the necessary improvements to the service.”
infection control
2 findings
moderate“We were not assured all members of staff employed at the service had received appropriate training relating to infection, prevention and control, COVID-19 or 'donning' and 'doffing' training.”
critical“The registered manager had failed to follow current government guidelines for undertaking COVID-19 testing. Staff had been provided with weekly rapid Lateral Flow Devices [LFT] instead of the recommended PCR test.”
consent capacity
1 finding
moderate“Where restrictions were in place, the reason for the restriction was not recorded to evidence these had been agreed as part of 'best interest' procedures.”
missed or late visits
1 finding
moderate“The current arrangement of staff notifying the provider through an instant messaging platform...was ineffective and inconsistent.”
leadership
1 finding
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
other
1 finding
critical“the registered manager had not obtained references or Disclosure and Barring Service [DBS] checks prior to staff starting work at the service.”