critical“MAR did not always accurately record what doses people were administered or if those medicines were given in line with manufacturers guidelines.”
critical“One person was prescribed a pain-relieving medicine...MAR did not evidence that the required gap was consistently being maintained between doses.”
critical“Staff told us they crushed all medicines and gave with food, yet there was no instructions or guidance from a prescriber to ensure that those medicines were given safely.”
critical“Medicine Administration Records (MAR) did not always correlate with people's care plans. It was not always clear what medicines a person had been prescribed or if staff administered them.”
moderate“where people had medicines administered by staff on an 'as needed' basis, there were no 'as and when' protocols to tell staff, when and how to give those medicines.”
care planning
5 findings
moderate“For one person with diabetes, there was no care plan which meant staff did not have important information to know how to manage any high or low blood sugars.”
moderate“On 9 October 2023 the provider told us they had supported a person with personal care and a personal care plan needed to be completed...this had still not been completed.”
critical“One person had diabetes. There was no diabetes risk assessment or care plan to direct staff on how to identify concerns relating to safe diabetes practices.”
critical“we found risk management plans were not always updated to reflect changes in people's needs and abilities. Gaps in risk assessment tools in some care plans”
moderate“in each of the care plans we reviewed; those plans lacked detail especially when those needs had changed”
incident learning
4 findings
critical“We identified 2 separate incidents that had not been captured in the provider's overall analysis of accidents and incidents.”
critical“A serious injury was missed off July 2023 analysis. This meant the provider was not aware of all incidents to take appropriate steps to investigate.”
moderate“The provider was not able to demonstrate an effective system for overseeing incidents and accidents to identify any themes or trends, reduce the risk of reoccurrence.”
moderate“there was no recorded analysis of those incidents to identify any patterns or trends to mitigate similar incidents from reoccurring.”
governance
3 findings
critical“Medicines audits were not always completed. Where those audits were completed, they failed to identify the issues we found.”
critical“Checks we would expect to be made such as late/missed calls, daily log completion, medicines management, care plans and risk assessments were non-existent.”
critical“The provider did not demonstrate effective governance, including assurance and auditing systems or processes. This was a breach of Regulation 17”
leadership
3 findings
critical“There remained no effective system of continuous improvement. There was a lack of effective reporting, investigation and referral of serious concerns.”
critical“"I haven't had any oversight. I haven't been on it (quality assurance) because I thought other people were. I accept the responsibility."”
critical“There was no effective leadership or accountability to resolve this in a timely way to promote a good outcome for this person.”
record keeping
3 findings
moderate“Some MAR had gaps which meant we could not be sure those people had been given their medicines as prescribed.”
moderate“There was a lack of order in record keeping and some documents, audits and checks we asked for could not, or were not, made readily available to us.”
moderate“the registered manager told us they thought their own paperwork and records would let them down because they were not thorough enough.”
safeguarding
2 findings
critical“In three examples, the provider failed to notify us of those incidents which was their legal responsibility.”
critical“Staff lacked confidence to share their concerns with the provider...staff shared information with us about specific examples that should have been referred to the local safeguarding team.”
staff competency
2 findings
critical“The provider told us about one staff member who worked under the identity of another person. There were no records to support safe employment checks were completed at all.”
critical“we found staff did not always use the hoist from the commencement of this person's care. Instead, staff used an unapproved technique which had potential to cause this person serious harm.”
communication with families
2 findings
moderate“When things did not go to plan, relatives said there was no explanation or apology given. This happened frequently when staff were swapped last minute.”
moderate“staff lacked confidence in communicating with management about issues or concerns they had. Staff told us when they had raised concerns, these were not acted upon.”
consent capacity
1 finding
moderate“There was no formal assessment or best interest meeting to determine the best outcome for that person...staff deferred to family members instead of seeking that person's consent.”
person centred care
1 finding
moderate“There was no formal process for people and relatives to provide their feedback about the service. Some relatives told us...their concerns and opinions went unheard.”