critical“The management of medicines was ineffective and placed people at risk of harm. People did not have personalised protocols for "when required" (PRN) medicines”
critical“MAR charts contained hand- written modifications and there were discrepancies between MAR charts and care plans.”
care planning
1 finding
critical“Care was not planned in a personalised way. Care plans were long with a large number of headings and sparse information was often repeated throughout”
person centred care
1 finding
critical
“The registered person did not design care with a view to achieving service users' preferences and ensuring their needs were met. 9(3)(b)”
governance
1 finding
critical“Audit processes were not effectively designed to monitor and improve the quality of the service.”
incident learning
1 finding
moderate“Policies and processes were not used appropriately to learn lessons from incidents and accidents.”
record keeping
1 finding
moderate“Records around medicines administration were not clear and care plans were not up to date.”
staffing levels
1 finding
moderate“There are times they can't send anyone. I did raise this with [the registered manager]. She is trying her level best.”
staff competency
1 finding
moderate“[Our care worker] is not very experienced. [They] have had training but I don't think it is enough”
communication with families
1 finding
moderate“The service was not meeting the AIS. Information about people was in large and inaccessible documents.”
leadership
1 finding
moderate“The registered manager did not always understand regulatory requirements.”
other
1 finding
critical“the provider had not assessed the risks of staff carrying out these tasks.”