critical“Medicine risk assessments and risk management plans were not always in place. For example, there were no risks identified or guidance in place for staff as to what they should do if people refused their medicines.”
minor“The medicines policy did not give staff any guidance about what to do in the event of a medicines error.”
moderate“one MAR record for prescribed creams had not been returned to the office for checking in July and we identified two gaps that needed to be reconciled”
moderate“a body map inaccurately showed the location where the prescribed cream needed to be administered. There was a risk this could be incorrectly applied by unfamiliar care workers.”
critical“Medicines were not managed safely and people did not always receive their medicines as prescribed.”
critical“medicines errors had occurred due to missed calls or calls occurring too close together and the risks in relation to medicines had not been identified or assessed.”
governance
6 findings
critical“The provider's governance of the service was not effective or robust. There was a lack of oversight, leadership and governance at the service.”
critical“records related to the monitoring of the service and staff records were not always available. Some policies were inaccurate or not available for staff as guidance”
moderate“the process for checking these records had then recently started and it was not possible to judge its effectiveness. This remained the case at this inspection and so this system was not yet working satisfactorily.”
minor“Staff meetings were not held which meant opportunities to discuss consistency or common issues were limited.”
moderate“not all MAR had been returned for the month of July and this had not been identified as there was no system to check for this.”
critical“Systems to assess, monitor quality and mitigate the risks relating to the health, safety and welfare of service users were not operated effectively.”
record keeping
6 findings
moderate“Records were not completed fully and accurately. The lack of risk assessments and risk management plans did not demonstrate the provider always understood how to assess and manage risks.”
moderate“Of the 11 care plans we looked at five had no record of telephone monitoring or quality visits for this year.”
minor“We found two care plans that were hand written and difficult to read in parts.”
moderate“regular checks were not always carried out on the daily notes being returned to the office to confirm that people received their care as planned.”
critical“communication logs for two people did not always evidence that the care and support provided was in line with the support plan.”
critical“For one person there was no record of calls provided on four occasions.”
missed or late visits
4 findings
critical“One person said, "Some come when they feel like. They don't think of me. One should have come at 10.30am but came at 2.45pm."”
moderate“Seven people told us they had experienced late calls on occasions...Three people told us their calls were more regularly late.”
minor“We noted that there were some late running calls and the office manager told us the reasons for the late calls had yet to be identified.”
moderate“missed and late visits had not been promptly identified for someone using the service in the other local authority where no call monitoring service was provided.”
care planning
3 findings
critical“Risks to people in relation to diabetes, falls and choking were not always identified and there were no risk assessments or guidance for staff on what to do to minimise these risks.”
minor“the service had yet to complete its full review of people's care and support needs... this process was three quarters of the way through had not yet been fully completed.”
critical“risk assessments for four people did not identify risks from their respective health conditions or other associated risks.”
staff training
3 findings
moderate“six care workers safeguarding adults training was overdue and five care workers manual handling refresher was also overdue”
moderate“The provider did not refresh care workers training for areas such as food hygiene, Mental Capacity Act, dementia care and infection control to ensure that care workers remained up to date.”
moderate“care workers did not always demonstrate full understanding of the code of practice and their responsibilities under the code.”
staff competency
2 findings
critical“The provider did not have a regular formal process to assess whether staff were competent to administer and manage people's medicines safely.”
moderate“Checks to ensure new care workers had completed their shadowing and were skilled enough to carry out the work had not been completed or signed off for one person.”
incident learning
2 findings
moderate“Accidents and incidents were recorded, however the provider failed to carry out any analysis and disseminate any learning to staff on how to minimise these in the future.”
moderate“Regular staff meetings to share any learning had not been held for the last year.”
consent capacity
2 findings
critical“Arrangements for staff to follow the Mental Capacity Act (2005) Code of Practice were not in place and staff did not have sufficient knowledge of their roles”
moderate“Some support plans had been signed by relatives when it was unclear if the person concerned lacked the capacity to make this decision.”
communication with families
1 finding
minor“People told us that communication with management could be better. One person said, "They [management] don't always get back to me."”
staffing levels
1 finding
critical“the provider did not ask for a full employment history to protect people from the risk of being supported by unsuitable staff. This was a breach of Regulation 19”
safeguarding
1 finding
moderate“personal references for two new staff members had not been verified and a risk management plan for a new employee and checks on their induction completion had not been followed.”