critical“gaps in signatures in medicines administration records (MAR), had not always recognised as a potential medicines error nor acted on”
critical“Another person had not received some of their medicines for 5 days as they run out of stock. Although some action was taken to minimise the risk to them, the action was delayed”
moderate“Another person's medicines records showed discrepancies which were not clearly addressed in spot check audits.”
care planning
3 findings
critical“electronic records for all people we reviewed did not provide any detail around specific risks to people, such as personal care, health needs, moving and handling”
critical
“one person had been supported for over 5 months at the time of the inspection and they had no risk assessments in place”
moderate“one person had a range of equipment and guidance in place on how to prevent them falling but this was not recorded in their risk assessments”
governance
3 findings
critical“provider had poor oversight of the overall safety and quality of the service...management team could not clarify how staff recruitment checks were monitored and audited”
moderate“incidents, accidents, complaints and feedback was recorded but not analysed to identify any patterns and lessons learnt”
critical“The provider had failed to ensure their governance systems were used effectively and failed to maintain accurate and complete records.”
missed or late visits
2 findings
critical“system report we reviewed stating staff attendance was only 53% compliant with planned timings in April 2023”
critical“one person's visit was planned for 60 minutes on the morning of the inspection and we saw staff recorded a visit which lasted only 19 minutes”
staff training
2 findings
moderate“Multiple staff had out of date training, for example, in safeguarding, health and safety or medicines management. This was not clearly addressed in the provider's action plan.”
minor“there was limited evidence on how the provider assured themselves of staff's employment history and their conduct in previous employment in social care”
record keeping
2 findings
critical“provider had failed to ensure their governance systems were used effectively and failed to maintain accurate and complete records”
moderate“people's care records did not always reflect their up to date needs clearly”
staff competency
1 finding
moderate“Not all staff had received appropriate training in safe management of medicines and competency assessments”
staffing levels
1 finding
critical“provider had failed to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons were adequately deployed to attend care visits as planned”
incident learning
1 finding
moderate“The provider did not always learn from adverse events in the service and people's feedback. The incidents, accidents, complaints and feedback was recorded but not analysed”
safeguarding
1 finding
critical“local authority looked into other concerns of staff unauthorised presence in people's homes...additional staff visiting their homes did not record their attendance on the staff monitoring system”
leadership
1 finding
moderate“registered manager provided assurances to CQC prior to the inspection stating all improvements had been completed. However, we identified multiple people did not have an up to date care plan”