critical“Medication administration records (MARs) were written by the service. However, the information recorded was not sufficient to ensure the possible risks with administration were mitigated.”
critical“people who needed to have their medicines administered directly through a Percutaneous Endoscopic Gastronomy (PEG), there were no robust clinical protocols in place”
critical“Care staff made us aware of two incidents relating to no medicines in the home for a period of up to three and five days respectively.”
care planning
1 finding
moderate“documentation for somebody diagnosed with type 2 diabetes had a risk assessment in place. However, it did not provide any information relating to signs staff should look out for”
governance
1 finding
critical“The provider had failed to establish systems and processes to assess and improve the quality and safety of the service provided.”
record keeping
1 finding
moderate“MARs were not always being completed by staff following the administration of medicines”
staff training
1 finding
moderate“Staff we spoke with had very little understanding of PRN (as and when required medicines) protocols.”
incident learning
1 finding
moderate“incidents and accidents had not been formally recorded or notified to the appropriate organisation even though the provider had confirmed a system was in place.”
infection control
1 finding
moderate“we were not assured all staff were following this policy regarding COVID-19 testing for staff. Staff are required to self-test twice weekly; the provider was unable to provide evidence of this.”
other
1 finding
moderate“The provider had not ensured safe recruitment practices were being followed. We looked at two recruitment records. For one of the applicants, references had not been certified”
missed or late visits
1 finding
moderate“information that we received highlighted several missed and unassigned visits... there was no recorded analysis of this information. This meant there was a possibility people weren't receiving planned care calls.”
complaints handling
1 finding
minor“An analysis of the information gathered was produced and highlighted some concerns with staff accents and communication. This concern was due to be followed up at the next team meeting, however this did not take place.”