critical“One person had not received their medicines, prescribed for the management of their epilepsy, for four consecutive days. This significantly increased the risk of them having a seizure.”
critical“Documentation did not ensure the safe administration of people's medicines. One care record stated staff could administer a medicine to control a person's seizure, but this was incorrect.”
critical“one instruction was 'two in the morning', but the dosage of the medicine was one tablet. This increased the risk of a medicine's error.”
critical“some time specific medicines had been given too close together, which increased the risk of the person being overdosed.”
moderate“the provider had failed to keep an accurate record of the medicines they had supported people to take”
critical“The provider failed to maintain an accurate record of the medicines staff had supported people to take.”
care planning
4 findings
moderate“Care planning focused on tasks and outcomes and was not always person centred. Health conditions were stated in people's care plans, but the information was generic and not specifically related to the individual.”
moderate“people's health conditions and generic symptoms were stated, but guidance about the impact on the person was limited.”
critical“Risk management plans for one person did not include information about significant tissue and bone damage they had experienced.”
critical“Another person had a risk assessment which stated they were at high risk of pressure ulcers. The risk management plans did not detail how to mitigate the high risk.”
record keeping
4 findings
critical“Skin integrity risk assessments had not always been completed correctly. One assessment identified a person was fully mobile and incontinent of urine, but they used a wheelchair and were doubly incontinent.”
moderate“topical creams had not been identified on the MAR. Some records showed staff where the topical creams were to be applied...but this was not the case for all records.”
moderate“Changes had been made to the way staff worked, to ensure they were able to maintain accurate records.”
critical“One person had no record of being supported with their medicine on 26 occasions. Another person had no record of support on 15 occasions and a third person had no record of support on 12 occasions.”
governance
4 findings
critical“The auditing systems had not assured the provider that safe recruitment practice was being followed. Daily and monthly checks of medicine administration systems were undertaken, but not all shortfalls were being identified.”
critical“Systems had not been established to assess, monitor and improve the quality and safety of the service. This placed people at increased risk of harm.”
moderate“failed to... have effective systems to assess, monitor and improve the quality of the service provided. This was a breach of regulation 17”
critical“The systems for monitoring the service and identifying required improvements were not effective.”
safeguarding
3 findings
critical“Risks were not always identified, assessed, or mitigated, which did not promote people's safety. The risk of choking, skin soreness and fire hazards when using petroleum-based emollients had not been identified.”
critical“an incident recently occurred which placed a person at significant risk of harm.”
critical“We identified three incidents which had not been notified to us. The incidents included one where a person had sustained a serious injury, one where a family member made an allegation of abuse and one where there was an allegation staff had neglected a person.”
incident learning
3 findings
moderate“Audits had identified there were occasions when staff were late arriving to support people, but further analysis had not been completed. Themes or trends had not been identified or addressed.”
moderate“an analysis of such concerns had not been considered. This did not give an overall picture of the frequency or circumstances of these situations.”
critical“The provider had failed to notify CQC of significant events in the service. This was a breach of regulation 18.”
staff competency
2 findings
moderate“3 job applications did not always demonstrate a full employment history, as gaps in employment had not been identified or verified. This meant safe recruitment decisions had not been made.”
critical“Records did not show recruitment processes were sufficiently robust to ensure staff recruited had the qualifications, competence, skills and experience.”
supervision appraisal
1 finding
moderate“Records showed one member of staff required more supervision, but there were no records to demonstrate this. There was no assessment of the staff member's competence to show they were able to carry out their role effectively.”
complaints handling
1 finding
moderate“The provider was not able to provide evidence of the complaints raised, their investigation or outcome. This did not demonstrate all complaints were addressed or that lessons had been learnt.”
person centred care
1 finding
moderate“One care plan showed the person had dementia, but not how it impacted on them or their support. This did not ensure staff were fully informed to provide support in the best possible way.”
communication with families
1 finding
minor“one relative told us they made a complaint about the staff not being able to communicate with their family member in English.”
leadership
1 finding
moderate“The service did not have a registered manager. The manager was a director of the provider and had applied to register with CQC.”