critical“We identified out of date medicines, some dating back to 2014, and used gloves in the bag. There was no itemised log or checks of what was in the bag.”
critical“Another person required their medicines to be crushed and administered covertly, but the provider did not have a best interest decision to support this.”
critical“The temperature recorded on the day of the inspection was 11°C, which could impact of the efficacy of the insulin.”
care planning
2 findings
critical“One person's risk assessment recorded they should be supported to eat a 'soft and bite-sized diet'. We observed they were given an orange segment, which caused them difficulty with swallowing.”
critical
“When we asked to show us risk assessments that included swallowing, asthma and epilepsy risk assessments, the provider told us these documents had been archived.”
consent capacity
2 findings
critical“We found the provider was not always working within the principles of the MCA. Best interest decisions for people who did not have the mental capacity to make specific decisions were archived.”
critical“One person used restrictive equipment such as bedrails but we did not see consent for their use or a best interest decision regarding their use.”
governance
2 findings
critical“Medicines checks were not effective as they had not identified the concerns we found with the management of medicines, including out of date medicines, incorrect temperatures.”
moderate“A number of documents could not be provided on the day of the inspection and had to be sent days later. Not all risk assessments were accessible on the day.”
record keeping
2 findings
moderate“Risk assessments were not always dated to indicate when they had been completed and therefore it was not clear if they were up to date.”
minor“The records for one person we looked at did not match the cash amount or reconcile with the receipts total.”
incident learning
1 finding
moderate“It was not always clear what action had been taken to reduce the risks of the incident reoccurring. Team meeting minutes did not include any of the specific incidents.”
infection control
1 finding
moderate“In a toilet, we found a bucket with two soiled mops. Although colour coded for different areas, they had been placed in the same bucket, risk of cross contamination.”