critical“Important information about when and how medicine required as and when (PRN) should be administered was missing from people's care plans.”
critical“There were gaps in people's medicine administration records (MAR). Although we could see there were reasons for the gaps by cross referring to other documentation this was not a safe way.”
critical“People's medicine administration records were not always completed accurately. It was not always possible to confirm if people had received their medicines as intended”
governance
3 findings
critical“Audits did not maintain a good oversight of all aspects of the service delivered to people. People's care records and risk assessments were not always accurate or up to date.”
moderate
“Systems to monitor care calls were ineffective, the provider had not identified where calls overlapped. The provider had no system in place to identify when calls were cut short.”
critical“There were no formal quality assurance systems and processes in operation. There was no development or service improvement plan in operation”
care planning
2 findings
critical“Care plans continued to lack important information and guidance for staff to refer to when supporting people with specific health needs such as diabetes, epilepsy, and catheter care.”
critical“There was not enough guidance or information available in care plans and risk assessments about how to safely support some people who required support with complex health needs”
record keeping
2 findings
moderate“Information was missing from care plans about people's holistic needs which could impact their mental health and wellbeing. Some of the information in care plans was inaccurate and contradictory.”
moderate“People's care records and risk assessments were not always accurate or up to date. This presented risks to the safety and quality of people's support.”
staff training
2 findings
minor“Others said training needed to improve as it was mostly eLearning (computer-based learning) and they would prefer more practical training.”
moderate“systems to identify when staff required additional or updated training were not operating effectively. Some staff required re-fresher training”
staffing levels
1 finding
critical“Calls to people were planned in a way that did not account for travel time and overlapped. Staff said, 'I was running from one to another, driving like a maniac to get there.'”
missed or late visits
1 finding
moderate“Staff don't turn up on time if other people ill. My early morning call is later, it should be earlier.”
communication with families
1 finding
minor“I do feel like communication with managers not the greatest. They could touch base more. Personally, I don't feel well communicated with and involved.”
leadership
1 finding
moderate“Statutory notifications had not always been submitted as required, and the registered manager was not aware of their responsibilities to do so.”
incident learning
1 finding
moderate“Quality and safety issues such as staff training needing renewal, risk assessments not being completed or monitored... had not been identified and had continued occurring over long periods.”