critical“care workers were not always recording when they were supporting people with medicines and therefore we could not be sure medicines were being managed safely.”
moderate“PRN medicines did not always have separate medicine protocol guidelines... some staff were signing the MAR with only one initial instead of two.”
care planning
1 finding
critical“risk assessment was a tick box to indicate an assessment had been completed but there were no details of the actual risk and its severity and there were no risk management plans.”
consent capacity
1 finding
critical
“the provider did not have a good understanding of the requirements of the MCA as the best interests decision checklist was not decision specific and was not fully filled out.”
governance
1 finding
critical“There were no audits to identify these discrepancies, so the provider had not identified those shortfalls and could not take action to address these.”
end of life care
1 finding
moderate“the care plans did not contain any information around people's wishes, views and thoughts about end of life care as this had not been considered as part of the care planning process.”
communication with families
1 finding
moderate“There was a lack of accessible information for people and care plans lacked communication support details.”
supervision appraisal
1 finding
minor“As none of the care workers had been with the provider for longer than three months, they had not yet had supervisions or appraisals.”
person centred care
1 finding
minor“one care plan stated about religion, 'Just respect my faith', which did not give the care worker any guidelines about how to support the person's faith.”
record keeping
1 finding
minor“One person's MAR used the code 'T' but there was no explanation of what it meant.”
staff training
1 finding
moderate“One staff member had references from a non-care employer and a friend but not the care agency they were working for at the time of their application.”