critical“Staff did not always record when they had given people medicines on their electronic Medicine Administration Record (eMAR). For some of these instances other records conflicted the eMAR.”
moderate“Protocols to guide staff how to administer medicines to people 'as required' were not always in place. Where they were, some staff told us they did not always know where to locate these.”
governance
1 finding
critical“Systems and processes in place to monitor the quality and safety of the service were ineffective. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance)”
incident learning
1 finding
moderate
“Opportunities to learn from incidents had been missed, as we could not identify how many accidents and incidents had occurred across the service or determine whether themes and trends had been identified”
care planning
1 finding
moderate“Some people's care plan reviews were overdue meaning care plans were not always reflective of their current needs.”
supervision appraisal
1 finding
minor“Some staff supervisions were overdue. However, staff we spoke with felt well supported in their role.”
end of life care
1 finding
minor“Care plans did not reflect people's preferences and wishes should they reach the end of their life.”
record keeping
1 finding
moderate“Audits of care records did not identify where improvements were needed. We found care plans did not always detail peoples current care needs.”
missed or late visits
1 finding
moderate“The provider failed to establish systems to monitor care calls, which restricted their ability to identify risks and address shortfalls.”