critical“Two people were given medication with food or fluids however, there was no covert administration documentation in place. A pharmacist had not been consulted.”
critical“Not all staff were trained in oxygen therapy. One person's administration for oxygen therapy was not correct.”
care planning
1 finding
moderate“Risk assessments did not always include detailed information about specific risks. One person used a wheelchair, however there was no information about the use of their harness.”
governance
1 finding
critical“Systems were not robust enough to demonstrate effective monitoring of the quality of the service. This was a breach of Regulation 17 (Good Governance).”
incident learning
1 finding
critical“We identified 5 incidents which had not been reported to the CQC.”
missed or late visits
1 finding
moderate“Staff visits were not audited to ensure missed or later visits did not occur. People and their relatives told us visits were often cancelled or missed due to staff sickness.”
record keeping
1 finding
moderate“Records were not always detailed or accurate. We found issues relating to records within risk assessments, medicines and quality assurance processes.”