CQC Inspection Action Plan

Inspection Date: 13th May 2021

 

The full report is available to download & read here with full responses detailed below.

Issues raised under SAFE

Issue Raised - 1

SAFE - Safe processes for medicines were not always adhered to and records were unclear. Example: when PRN medicine were often recorded on the medicine record sheet as offered but refused, while being recorded on the PRN records as given. Staff were making individual judgements about when to offer and how to record PRN medicine. This meant people could not be assured of receiving their medicine safely.

Issue Raised - 2

SAFE - Medicines were not always received, stored and administered and diposed of correctly.

Issue Raised - 3

SAFE - PRN protocols for medicines prescribed for pain relief that required more specific stroge and monitoring measures were not sufficiently detailed and did not guide staff on next steps if medicine was refused. This had resulted in a person not receiving the pain relief they needed.

Issue Raised - 4

SAFE - Staff were not following safe practice requirements or the providers own policy and training for giving medicines. Example: we observed staff signing the medicine administration record before the meidcine was given to the person rather than after. This was raised with the Registered Manager who spoke to the staff during the inspection.

Issue Raised - 5

SAFE - Risk Assessments for people were generic and not personalised. They lack detail and personailsed information relating to specific heath care needs. Example: one persons risk assessment had type 2 diabetes recorded as a risk but the assessment had not identified what the risks of this condition were or what actions staff neede to take to mitigate the risks. Staff understanding of diabetes varied, training had been sourced but not implemented at the time of the inspection. This meant that people could not be assured of receiving appropriate and safe care and treatment to manage their diabetes.

Issues Raised under WELL-LED

Issue Raised - 1

WELL-LED - The Registered Manager told us they contacted a company to provide them with updated policies and procedures, however, this had not resulted in improvements to assessing and recording peoples needs and choices.

Issue Raised - 2

WELL-LED - Processes fro audting medicines had failed to identify staff did not have enough guidance to enable them to sfaely make decisions about when to offer PRN medicines and what steps to take if people refused.

Issue Raised - 3

WELL-LED - Systems and processes for quality monitoring were mot effective and had failed to identify the lack of detailed health information in peoples care records. Some information contained within care plans was not up to date and not reflective of peoples current care needs. Although there was an update sheet in place that had breif details of changes to peoples needs, risk assessments were not updated to reflect the changes identified.

Issue Raised - 4

WELL-LED - Processes for quality audit had failed to identify a lack of personalised information within peoples care plans and risk assesments. Peoples preferences and abilities had not been captured. There was a lack of guidance for staff to ensure they provided personalised support in line with peoples preferecnes and needs.