critical“One person was prescribed two tablets to be given at the same time for two of their medicines, but staff were recording only one tablet was being given of each medicine.”
moderate“Medicines which were noted as 'when required', also known as PRN medicines, did not have PRN protocols in place to guide staff when the medicine may be needed.”
governance
2 findings
critical“Quality assurance systems were not fully effective and embedded to ensure the quality and safety of care was monitored. Breach of Regulation 17: Good governance.”
moderate“The operations manager had a basic action plan in place. They acknowledged it was not detailed as they felt their plans were mainly in their head.”
record keeping
1 finding
moderate“Actual call times when staff attended were not recorded and the specific details of the calls were not recorded.”
care planning
1 finding
moderate“Other records we viewed for other people did not always have sufficient details, missing information and no risk mitigation details.”
consent capacity
1 finding
minor“The operations manager told us they checked people's LPOAs. However, the evidence of these checks was not provided to us as part of the inspection.”
leadership
1 finding
moderate“The registered manager had been open and honest with us and had explained they had not been very involved with the service and had not been fulfilling the registered manager role.”