critical“MAR charts had gaps. This meant it was not always possible to tell if the medicine had been given and not recorded, missed, refused, or if there was another reason.”
critical“Records showed where one person had been given paracetamol without leaving the required four hour gap between administrations.”
governance
1 finding
critical“Systems and processes to check on the quality and safety of services were not operated effectively...audits on medicines management and care documentation had not been completed.”
record keeping
1 finding
critical
“Records were not complete. Records for the administration of topical medicines were not kept. Some daily visit records of the care provided to people had not been completed.”
staff training
1 finding
moderate“Not all care staff had provided a full employment history. There was not always evidence to show the provider had sought to understand gaps in care staffs' employment history.”
care planning
1 finding
moderate“Care plans identified a person had chronic obstructive pulmonary disease but did not describe how much this affected the person and whether anything associated with this condition would affect care.”
consent capacity
1 finding
moderate“One person's assessment stated they did not have the capacity to understand their medicines and finances and there was no further mental capacity assessment or best interest decision making recorded.”
end of life care
1 finding
moderate“There was limited evidence to show people had been asked about their end of life care planning and how care staff could best support this.”
communication with families
1 finding
minor“Some relatives told us they would prefer information on their family members' care plans and records in a non-digital format...some relatives did not feel the non-digital option had been offered to them.”