moderate“Some people needed medicines on an 'as and when' (PRN) basis...These had not consistently been completed. This was an area for improvement.”
moderate“Hand written MARs need to be checked by another person and double signed to ensure that these were accurate, and this had not been done.”
moderate“Where people were taking as and when medicines (PRN's) such as pain relief there were no protocols in place to inform staff what the medicine was for.”
governance
2 findings
critical“The provider failed to improve the quality and safety of the service. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.”
critical
“There were no records to demonstrate that the providers had checked staff's full employment history...application forms had been accidentally shredded.”
care planning
2 findings
critical“Some people used bed rails to reduce the risk of falling out of bed. There were no risk assessments to guide staff on their safe use, for example to reduce the potential risk of entrapment.”
moderate“Risk assessments were not always consistent in that some risk assessments were not in place. For example, one person used a feeding tube...and there was a lack of information.”
record keeping
2 findings
critical“Full employment histories had not been consistently obtained. Some application forms noted only years of employment and not months.”
critical“The provider had failed to improve the quality and safety of the services and ensure that they maintained complete and contemporaneous records. This is a breach of regulation 17”
staffing levels
1 finding
moderate“There were several entries in staff care calls when there was no travel time assigned. Time had not been allocated for staff to change their personal protective equipment and go to the next call.”
infection control
1 finding
moderate“The service had received a complaint regarding a person being given food, and on another occasion medication, whilst sat on a commode. This action was neither hygienic, nor dignified.”
staff competency
1 finding
moderate“Staff competency, to ensure they were safe moving people, had not been completed.”