critical“We reviewed the Medicine Administration Records (MARs) for 11 people between September and November 2022 and found numerous gaps which could indicate people had not been given their medicines.”
moderate“People who had transdermal patches had no body map in place so staff could record where the patch was placed to help ensure that the site of the patch was alternated regularly.”
critical“We found an alert relating to one person's medicines running out where the registered manager had not acted. This meant the person was without this particular medicine for several days.”
care planning
2 findings
critical“One person had a catheter but there was no mention of this in the care plan available to staff when staff had some responsibility for the care of this person's catheter.”
critical“A second person was recorded as being on normal food, but in another area of their care plan that they have pureed food. This person was also at high risk of falls, but there was a lack of guidance.”
governance
1 finding
critical“No further audits had been conducted since, despite 20 people now receiving care from the agency.”
record keeping
1 finding
moderate“Information across the care records did not always match or was incomplete. One system recorded a person as having a catheter, but on the other system that they used incontinence aids.”
incident learning
1 finding
moderate“The registered manager had an extremely good knowledge of incidents that had occurred to date. However, they did not collate this information to allow them to look for themes and trends.”
consent capacity
1 finding
moderate“Some people's capacity assessments were blank and in one person's care plan it gave contradictory information in that it stated the person could make decisions, but in another area that they lacked capacity.”
missed or late visits
1 finding
minor“I had to phone the office at nine as no one had turned up for my 8am call. Someone came straight away and, In the morning it should be 07:30, but sometimes it's 09:30.”