minor“stocks of medicines were occasionally not available... some families were responsible for ordering medicines and staff prompted them to re-order, but this didn't always happen.”
critical“Where people were prescribed 'as required' medicines there were no protocols in place guiding staff when to administer the medicines.”
critical“Where people were prescribed topical medicines there was no record of the medicines on medicine administration records (MAR).”
missed or late visits
1 finding
minor“five people reported some issues with timekeeping. One person said, 'They provide what I've asked for and mostly arrive on time but if not, they should let me know'”
infection control
1 finding
minor“not all staff were consistently wearing full PPE as guidance required... 'They do now use masks, aprons and gloves, but odd ones do not fully use them'”
staff competency
1 finding
critical“Staff were not always trained, and their competency assessed to ensure they could administer medicines safely.”
incident learning
1 finding
critical“no incident or accident form had been completed and no investigation had been completed.”
governance
1 finding
critical“Systems for monitoring and improving the service were not effective as they had not identified the issues we found during the inspection.”
leadership
1 finding
moderate“The provider did not have a clear understanding of their regulatory responsibilities. This had resulted in a breach of the regulations.”
consent capacity
1 finding
moderate“they were unaware of their responsibility to complete capacity assessments where there were indications a person may lack capacity to make a decision.”
staff training
1 finding
moderate“The provider's training matrix showed that staff had not completed training in dementia care.”
safeguarding
1 finding
moderate“staff were not always aware of the external agencies they could notify if needed.”
end of life care
1 finding
minor“The care plans we looked at did not contain information relating to end of life wishes.”
record keeping
1 finding
moderate“MAR did not always include the details of individual medicines to ensure staff had the information required to administer medicines safely.”