Areas of Service:  Safe

Action Nos

Context in Report

 Action Steps

1

Risk assessment were very brief and did not always contain adequate information for staff

New systems now in place to ensure comprehensive care plan is in place for each client. Full risk assessment is been completed prior to care commencement and are fully detailed in the client’s care plan.

2

Identified risks often did not have a corresponding management plan

A detailed corresponding management plan is now in place for every identified risk and adequate documentation is in place.

3

In addition, where risks were managed in conjunction with other professionals, the full details were not always documented.

More information are now been added to all investigation report highlighting what we have learnt from each incident and how we are working to prevent such reoccurrence. We have also implemented a new method of creating our care plans to make it more detailed and comprehensive.

4

Staff competency to administer medicines had not been assessed since the start of the COVID-19 pandemic.

Competencies for medications have now commenced with face-to-face meetings.

5

They needed to consider how they could safely re-introduce competency assessments.

Competency assessments are been done my the registered manager and the care coordinators.

6

There was not always sufficient information documented within the medicines section of people's care plans.

New medication administration record has been designed to include a larger portion for additional comments so that carers have more information about the medications.

7

Guidelines were not in place for "as required" (PRN) medicines

New medication charts now have all the details on how and when to administer PRN medicines.

8

The registered manager explained that is was policy to obtain two references, however, sometimes these were given verbally. These verbal conversations were not documented.

Verbal references are now documented in the staff record and mostly references are obtained in written format.

9

Investigations, actions taken, and lessons learnt were not consistently documented.

New investigation report have been implemented which now has all full report showing the lessons learnt, actions taken to prevent such occurrence again.

Areas of Service:  Effectiveness

Action Nos

Context in Report

 Action Steps

1

More opportunities to shadow more experienced members of staff.

Now that restrictions are been lifted, new staff will be given a shadow shift before commencing work.

2

Staff told us that they did not receive regular formal supervision but had a lot of informal contact with the registered manager.

Formal supervisions are commencing from June 2021 as covid restrictions are now been lifted across the country.

3

However, we did not see documented evidence that people had consented to the care package put in place by Nursing Care Personnel.

Consent were taken over the phone verbally from clients but now is documented in all care plans with the date and name of who gave the consent.

Areas of Service:  Service Responsive

Action Nos

Context in Report

 Action Steps

1

However, the care plans we viewed were basic and lacked guidance for staff regarding how they could provide support in a person-centred way.

New implementations are in place to provide more detailed care plans so that carers have full details of how to provide person-centred care.

2

Care needs were identified but there was a lack of detail about how care should be provided, and these needs met.

More details are now provided in the new care plans which also include how the needs of the client can be met, who the staff can contact for more support etc

3

There were too many discrepancies in the information given and the actual needs of the service user

Now that restrictions are lifted, face to face assessments will be done which then gives accurate and precise needs of the client which will be evident in the detailed personalised care plan.

4

Relatives were not always aware that there was a care plan in place

All relatives and clients are informed that the assessments been carried out is to produce a personalised care plan for the client.

5

People's communication preferences were briefly outlined in care plans, however, sometimes more information could have been provided, especially where people were unable to communicate verbally. 

Communication preferences of clients are now stated in care plans in a detailed manner so that staff can know how best to communicate effectively with their clients.

6

The registered manager was able to give examples of where people had been supported to have a dignified death. However, people's preferences were not consistently documented in care plans. We did not see any evidence of completed advance care plans. 

A new section is now on the care plan which highlights the client’s preference in the event of death and what they will like the staff to do when that situation happens

7

Staff told us that they would like additional face to face training in this area. The registered manager told us she was considering options for this, once COVID19 restrictions had lifted.

Training for specific end of life training are been implemented and made available for all staff to attend from July 2021 ongoing.

Action Nos

Context in Report

 Action Steps

1

The registered manager had started to introduce quality assurance and auditing processes.

Quality assurance and auditing systems are now fully in place and are now been updated on a weekly basis.

2

However, limited consideration had been given to business continuity in the event of the registered manager becoming incapacitated.

A new position is now been advertised for a deputy manager to be in place to work alongside the registered manager and the position will commence from July 2021.

3

Discussions with the registered manager suggested that incidents, complaints and safeguarding concerns were followed up in a satisfactory manner. However, systems were not in place to ensure all evidence was collated, actions were formally documented, and lessons learnt identified

All incidences, complaints and safeguarding concerns are now fully documented, audited to get trends of occurrences and lessons learnt to prevent them reoccurring again. This is ongoing.

4

Furthermore, incidents were not analysed for patterns or trends, limiting management oversight of the service.

Auditing of all incidents are now done on a weekly basis and is ongoing.