critical“Individual protocols for the use of 'when required' (PRN) medicines were not available. This was a finding of the previous inspection.”
critical“In four cases, the transcriptions did not specify the dose of medicine required. Failing to state the required dose on a MAR could put the person at risk of receiving the wrong dose.”
care planning
2 findings
critical“People's risk assessments did not contain clear and detailed guidance for staff to protect people from the risk of harm.”
critical“Comprehensive care plans and risk assessments were not available for all people... this put people at risk of not receiving appropriate and safe care.”
governance
1 finding
critical“The registered manager had not established an effective system to enable them to ensure compliance with their legal obligations and the regulations. Regulation 17 (1, 2, a, b, c)”
incident learning
1 finding
moderate“The management team had not analysed themes and trends in the accident and incident reports, and ensured measures were in place to reduce the likelihood of repeat events.”
supervision appraisal
1 finding
moderate“Supervision records identified that some staff members had not received supervision for at least four months. This was not in line with the provider's policy.”
missed or late visits
1 finding
minor“There had been times were staff were more than 30 minutes late to the agreed time. One person told us, 'I've had occasional missed calls'.”
record keeping
1 finding
minor“A person was due to have their morning call at 9am, however, staff had arrived at 6:30am... audits had failed to identify a disparity between the time a staff member arrived and the scheduled time.”