critical“Medicine for 1 person had not been transcribed correctly on the Medication Administration Record (MAR) chart. There was inconsistent information about the prescribed dosage.”
critical“Medicine Administration Records (MAR) contained missed signatures...prescribed creams were not included on the MAR to evidence these had been applied as required.”
critical“When people required medicines as and when (PRN), the correct PRN protocols were not in place and there was no guidance to inform staff when to administer these medicines.”
governance
3 findings
critical“There had been no quality assurance audits undertaken by the provider or their representative for 12 months.”
critical
“Audits had not been completed in line with the providers procedures...all the shortfalls found during the inspection had not been identified by the provider.”
critical“There was a lack of oversight and systems to monitor the service were not effective. Audits had not identified the issues we found during inspection.”
record keeping
3 findings
critical“Medicine that has been prescribed as a short course, was incorrectly recorded on the 'as and when required' (PRN) section of the MAR chart.”
critical“Staff had not consistently recorded repositioning tasks, skin integrity checks and when creams were applied to people's skin. We found multiple gaps in these records.”
moderate“Incorrect personal information contained within risk assessments was duplicated across several different people's care plans and this had not been identified during audits.”
missed or late visits
2 findings
moderate“We received feedback from people and their relatives that staff left some care visits early and logged out of the electronic system away from people's home.”
moderate“[Person's] first morning call should be at 9.30am and the carer is not turning up until 11am.”
leadership
2 findings
critical“At the time of our inspection there was not a registered manager in post. A new manager had been in post for 2 months and had submitted an application to register.”
critical“The provider had not kept people's personal information safe. There had been two occasions of a personal data breach under General Data Protection Regulation (GDPR).”
care planning
2 findings
critical“There were whole sections of the care plan left blank for multiple people and the details of a person's living arrangements and environment were not always completed.”
critical“People's risks were not always appropriately identified and assessed. Staff were not always provided with clear guidance to manage people's risks.”
staff training
1 finding
critical“Not all staff who were administering medicines and supporting people with moving and handling tasks had received up to date training. This put people at risk of unsafe care.”
staff competency
1 finding
moderate“People were supported by staff who had not received up to date training or had their competencies assessed.”
safeguarding
1 finding
critical“The providers systems and processes had not identified a lack of satisfactory evidence of staff conduct in previous employment concerned with the provision of services relating to health or social care.”
incident learning
1 finding
moderate“There was no system in place to monitor accidents and incidents to identify possible trends and patterns.”
complaints handling
1 finding
moderate“Not all complaints received had been logged as a complaint therefore, they had not been investigated or responded to appropriately.”
consent capacity
1 finding
critical“Information within MCA assessments and care plans was often conflicting and we did not see evidence of best interest decision processes having been followed.”
end of life care
1 finding
minor“Care plans did not include information on end of life care and support.”