moderate“Known risks to people had not always been assessed. For example, one person who was at risk when crossing a road, had no risk assessment or strategies recorded”
medication management
1 finding
moderate“When people had 'as required' (PRN) medicines prescribed, records were not always completed to evidence the reason the medicine was administered.”
record keeping
1 finding
moderate“People's medicine administration records (MAR) were not consistently completed to evidence medicines were administered regularly. Some people had two separate MAR for the same medicines.”
person centred care
1 finding
moderate“some care plans had no personalised information recorded to support staff to understand how a person wanted to be supported or what actual tasks were required.”
governance
1 finding
moderate“Audits completed on daily records and MAR were ineffective... the current process only checked five random files a month. This meant it could be up to eleven months before these records were audited again.”
leadership
1 finding
moderate“The service did not have a manager in place who was registered with CQC.”
staffing levels
1 finding
moderate“one person who required two staff to support them, told us, they generally only had one staff attend their calls.”
incident learning
1 finding
moderate“Records of seizure activity were not always documented correctly. Staff had not recorded the type or description of the seizure witnessed for one person who had experienced three recent seizures.”
communication with families
1 finding
minor“eight people had recorded they were not 'kept informed of changes' or had not been 'contacted to see if they were happy.'”