critical“one person received their paracetamol before the required four-hour gap between doses. This put the person at unnecessary risk of overdosing.”
moderate“Medication records showed the stock balance of medicines was not recorded to enable accurate auditing of administration.”
record keeping
2 findings
moderate“medication records showed directions of medicines had been crossed out and changed with no explanation as to who authorised this or why.”
minor“The current rating for the service was not displayed on the provider's website as required.”
consent capacity
2 findings
moderate“mental capacity assessments were not decision specific and did not include a best interest decision as required by the MCA.”
moderate“One person's consent was signed by a family member, but there was no evidence the family member had legal authority to consent on their behalf.”
governance
2 findings
moderate“Audits were completed but did not highlight all of the issues we raised during the inspection, such as the recording of people's consent, risk management and medicines.”
minor“The minutes from meetings held in October 2022 and February 2023 were identical, raising question regarding their effectiveness.”
care planning
1 finding
critical“one person's falls risk assessment scored them as not at risk, however the care assessment reflected they were at high risk.”