critical“The directions on medicines administration records (MARs) for 2 people did not match the directions on the medicine's labels.”
critical“A person had been supported to take 2 doses of one of their prescribed medicines at the same time instead of at the prescribed times 3 times a week.”
care planning
1 finding
critical“Robust and detailed care plans and risk assessments were not always in place to provide guidance to staff on how to mitigate and manage risks relating to people's needs.”
governance
1 finding
critical
“The provider had failed to operate effective systems to assess, monitor, mitigate risks, maintain accurate and complete records and improve the service.”
incident learning
1 finding
moderate“Incidents had not always been investigated to identify any lessons to be learnt or any follow up actions to provide additional support to people.”
record keeping
1 finding
moderate“We identified concerns in relation to poor record keeping. For example, in relation to medicines, daily records and ABC charts.”
person centred care
1 finding
moderate“Care plans did not always reflect people's needs or strengths. Staff did not always have the information on how they should work with people to promote their independence.”
consent capacity
1 finding
moderate“For people the service assessed as lacking mental capacity for certain decisions, there were not always recorded assessments and best interest decisions in place.”
staff competency
1 finding
moderate“A relative told us they had to take the lead on supporting medical appointments for their relative due to the inconsistency in individual staff members competency.”
staffing levels
1 finding
minor“Many of the recruited staff were non-drivers which impacted on people's ability to access their communities.”
communication with families
1 finding
minor“Some relatives told us that communication was not always consistent, and it sometimes depended on which staff were working.”
leadership
1 finding
moderate“There is no leadership. It depends on which member of staff you interact with as to whether you are involved or if anything gets done.”