critical“MARs did not include a record of the individual medicines and what each medicine looked like from people's medicine blister packs, therefore staff had limited guidance”
critical“medicine dosage and administration instructions were not always recorded on the MAR and staff did not always make accurate records when they administered a person's medicines.”
governance
2 findings
critical“Auditing systems were not always robust and auditing processes had not picked up on the discrepancies we found during this inspection.”
moderate“The provider did not have a robust quality framework in place to drive service improvements, and was reliant on the local authority carrying out quality checks.”
care planning
2 findings
moderate“Care plans did not always contain information about people's culture or religion and how this impacted on their care needs.”
moderate“People's communication needs were not always detailed in the care records.”
missed or late visits
1 finding
moderate“Staff rotas showed there was no travel time between calls. Some people told us staff don't always arrive on time for their visits, and don't stay the full length.”
consent capacity
1 finding
moderate“People's initial assessments contained information about people's cognition. However, this information was not always included in people's care plans and the provider had no specific mental capacity assessments in place.”
record keeping
1 finding
critical“Systems had not been effectively established to ensure accurate and contemporaneous records were maintained. Regulation 17(2)(c)”