critical“Medicines were not always well managed. Medicines records were poor, medicines administration records (MAR) were not always complete, accurate and clear.”
staff competency
1 finding
critical“Staff confirmed that they had not been checked by management team to ensure they were competent to administer medicines following medicines e-learning training.”
care planning
1 finding
critical“Care plans were inconsistent across the service. Some lacked important information individual to the person. Two people did not have a care plan at all.”
staff training
1 finding
critical“The training records did not evidence that staff had completed additional training to meet people's assessed needs such as catheter care, diabetes, skin integrity, choking and dysphagia.”
governance
1 finding
critical“The systems in place to audit the quality of the service were not embedded, robust or sufficient to alert the provider of concerns and issues within the service. No audits had taken place.”
record keeping
1 finding
moderate“Staff recruitment records showed gaps in three members of staff employment history. These gaps had not been addressed and recorded.”
missed or late visits
1 finding
moderate“People and relatives told us staff were often late and they were not informed, which was frustrating.”
incident learning
1 finding
moderate“records showed that one person's relative reported the person had fallen. The provider had not updated the care plan for the person to alert staff that the person was at risk of falls.”
leadership
1 finding
moderate“service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”