critical“records showed people had, at times, been overdosed on their medicines, under-dosed and/or received medicines without the appropriate amount of time left in between doses.”
critical“The service had two systems in place to manage medicines, an electronic one and a paper-based system...Having two systems running concurrently risked error.”
care planning
2 findings
moderate“care records were not consistently accurate or complete and they could not be relied upon to evidence what care and support had been delivered.”
moderate“The care plans we viewed were task based and did not evidence the person-centred care that people told us they received. Some were not accurate and contained inconsistent information.”
staff training
2 findings
moderate“Staff had not consistently received the training the provider deemed mandatory and the oversight systems in place had failed to rectify this.”
minor“staff had not received training in end of life care. As part of this inspection, the registered manager told us this is training they will now provide and make mandatory.”
governance
1 finding
critical“Whilst systems were in place to audit medicines management, risk assessing and care records, these had failed to identify or rectify the concerns found at this inspection.”
record keeping
1 finding
moderate“daily notes did not provide enough information for attending staff on what care had been previously delivered.”
missed or late visits
1 finding
moderate“people did not receive a rota and the records we viewed confirmed call times varied and did not consistently meet the times that had been agreed.”
incident learning
1 finding
moderate“due to the issues with the systems in place, we could not be assured all accidents and incidents were being recorded in an effective way that allowed full oversight and analysis.”
supervision appraisal
1 finding
minor“In November 2022, because of seeking feedback, staff had requested staff meetings take place on a regular basis. At the time of this inspection, these were still not taking place.”