critical“Medicines were not always safely managed... staff had only recorded the number of tablets they had administered to people on their MARs, they had not identified the types or doses”
care planning
1 finding
critical“one person's care plan identified them as needing support from staff to manage their catheter, but this had not been risk assessed and their care plan didn't contain any guidance”
person centred care
1 finding
critical“care plans did not always contain correct information about the support they needed, or identify any preferences they had in the way they wished to be supported”
governance
1 finding
critical“The provider's systems for monitoring the quality and safety of the service were not always effective in identifying issues or driving improvements.”
record keeping
1 finding
moderate“the ECM system showed missed visits for one person during the week of our inspection but on further investigation, the system had not been updated with rota changes”
staff training
1 finding
moderate“the medicines management training they had completed had not instructed them to maintain complete and accurate records relating to people's medicines”
staff competency
1 finding
moderate“the registered manager was not familiar with the detail of the national guidelines for managing medicines in domiciliary care which led to shortfalls in staff practice”