critical“guidance in the form of protocols or information in care plans was not in place to help staff give these medicines consistently.”
critical“For three people who were prescribed anticoagulants, guidance was not in place for staff in care plans to help staff monitor and manage their side effects.”
critical“One person's medicines were previously given via PEG...however their MAR and care plan was not updated. The records still outlined medicines to be given via PEG.”
critical“Four people who experienced seizures were prescribed medicines to prevent them. However, there was no information in the care plans for staff members on how to monitor or manage.”
care planning
2 findings
moderate
“One person's care notes included a choking risk identified but the importance of providing bite sized food had not been carried through to the care task section of the care plan.”
moderate“risks associated with some medical conditions such as diabetes and Parkinson's disease had not been assessed.”
missed or late visits
1 finding
moderate“78% of calls were delivered on time. 22% were more than 15 minutes late including 3% which were more than 45 minutes late. 15% of the calls were short calls.”
staffing levels
1 finding
minor“Calls requiring two care workers sometimes had staff arriving at different times.”
record keeping
1 finding
moderate“One had no employment history recorded and no references on their file. The other only had one suitable reference.”
consent capacity
1 finding
minor“Consent records were not always clear whether anyone had legal authority to make a decision on a person's behalf e.g. lasting power of attorney.”
end of life care
1 finding
minor“Some people had end of life plans; others did not have sufficient information about their wishes at the end of their life.”
governance
1 finding
moderate“the provider had failed to effectively identify the medicine issues we identified during this inspection...and failed to identify some areas where risk assessments were required.”