critical“MARs were not clear on when people needed their medicines... the time of the medicine's administration was not recorded so it was unclear whether the person had received them on time.”
missed or late visits
1 finding
moderate“of the 274 calls carried out, 78 were outside of the 15-minute leeway set by the funding authority. 30 of these calls showed staff were over an hour late.”
care planning
1 finding
critical“One person's care record stated that they had been referred to the service following hospital admission for frequent falls. Their person-centred risk assessment then stated they were at low risk of falls.”
governance
1 finding
critical“audits failed to highlight the services Electronic Call Monitoring (ECM) systems had recorded numerous late visits, with no evidence of action being taken in response.”
record keeping
1 finding
moderate“Records were not easily accessible... office staff had limited access to these records. For example, original medicines administration records, some care plans and areas of the ECM system.”
incident learning
1 finding
moderate“The provider had failed to identify some of the issues identified during this inspection.”
person centred care
1 finding
minor“Four people we spoke with told us the service did not contact them to seek their views or request they complete a survey.”