critical“We found evidence of at least three missed calls concerning two people over the space of two days. We were concerned the provider would not have known the calls were missed as there was no system in place.”
medication management
1 finding
critical“There were no protocols in place for PRN medicines...MAR audits highlighted numerous gaps where people's medicines may not have been given. When this had occurred, there was no record of follow up with 111, GP or medical practitioner.”
governance
1 finding
critical“There was no systematic means of picking up and following up on actions such as those recorded in the communication book...no system for recording interactions with medical professionals.”
incident learning
1 finding
moderate“It was not apparent whether incidents and accidents were being discussed regularly as there was no record of handovers and incident and or accidents were not a recurring item on team meeting agendas.”
record keeping
1 finding
moderate“There was no record of handover. This meant there was no way of knowing what exactly staff handed over from one shift to another and there was a risk that important information could be missed.”
end of life care
1 finding
minor“Care plans did not always contain information about people's end of life wishes. We discussed with the manager that there should be a consistent opportunity for this to be explored with people.”
staffing levels
1 finding
moderate“Staff told us, '[Staffing levels are] low. It can be hit and miss; we struggle at certain times. We have a few members off sick, we do our best to step in and cover [with] overtime.'”
leadership
1 finding
moderate“The registered manager was unavailable for this inspection through long term absence from work...people and relatives were unclear who managed the service. We were provided with four different names.”