critical“Some people's 'when required' medicines had been given as always required medicine and some people's always required medicine had been given as 'when required' medicine.”
moderate“The provider did not use body maps to record where people's medicine patches had been placed on their body. This meant the provider was not following NICE guidelines.”
incident learning
1 finding
moderate“The registered manager told us analysis of accidents and incidents was carried out annually. This meant lessons were not always learned in a timely manner.”
governance
1 finding
moderate
“The provider's audits had not identified the issues we found during our inspection.”
care planning
1 finding
minor“Some people's risk assessments did not include detailed and personalised information about their individual level of vulnerability to COVID-19.”
missed or late visits
1 finding
minor“They come twice a day but are always late, they can be from half an hour to an hour late. I do wish that they would call me when they are running late.”