moderate“Medicines audits were not being completed at the time of the inspection. The manager told us the electronic system flagged any issues which they would then address.”
minor“The CQC rating was not displayed on the provider's website in line with regulations. The provider had been made aware and told us they were addressing this; however, this had not been corrected.”
moderate“These audits did not highlight some of the issues that we found during inspection...people did not have PRN protocols in place”
record keeping
2 findings
moderate“Not all risk assessments were available to staff on the app and some information was in people's paper folders in their homes. Not all staff were aware of accessing the paper folders.”
moderate
“The registered manager could not always evidence they had taken a full employment history of some staff.”
medication management
2 findings
critical“Where people were prescribed 'as required' (PRN) medication, the service did not always have protocols or guidance in place for prescribed medicines or creams”
moderate“Staff had not always signed the associated medicine administration record (MAR) when people had been administered their medicines”
staffing levels
1 finding
minor“We received mixed feedback about the continuity of staff attending people's calls... One relative told us, 'It's a jumble at the moment with staff leaving. It's different ones coming'.”
care planning
1 finding
critical“For one person who was prescribed time specific medication, the guidance in their care file was not detailed enough.”
incident learning
1 finding
moderate“The registered manager had highlighted that accidents and incidents had not previously been recorded or reviewed.”
missed or late visits
1 finding
minor“The morning and evening calls are time specific, the [staff] are often late, I have called the office and they blame the [staff]”