critical“staff had administered doses of paracetamol to 3 people too close together. 1 person's records confirmed that had happened on 30 occasions in the 4 weeks prior to our visit.”
care planning
1 finding
critical“4 people had urinary catheters, but their care records lacked the information staff needed to help them identify and manage associated risks.”
record keeping
1 finding
critical“Accurate and up to date records in respect of each service user were not maintained.”
governance
1 finding
critical“weekly medicine audits had not identified the issues we found which placed people at risk of receiving unsafe care.”
missed or late visits
1 finding
moderate“I do not always get the 30 minutes support I should. It's more like 10 minutes, but they (staff) do arrive more or less on time.”
incident learning
1 finding
moderate“Lessons had not been learned and opportunities to make improvements had been missed.”