critical“The management of medicines was not always safe. The responsibilities of the care team and relatives when managing medicines had not been clearly defined”
moderate“Protocols for 'when required' (PRN) medicines, were not in place and body maps were not used to plot the location of patch medication.”
care planning
1 finding
critical“Risk assessments were not in place for people at higher risk to falls and for people with medical conditions which increased their risk of harm.”
incident learning
1 finding
critical
“Accidents and incidents had not been appropriately recorded and investigated. Incident forms were available but not in use at the time of the inspection.”
governance
1 finding
critical“Effective quality assurance processes were not in place and systems had not been developed for all relevant areas of the service.”
record keeping
1 finding
moderate“People's care records were not reviewed regularly and risk assessments were not updated where increased risk was indicated.”
consent capacity
1 finding
moderate“Mental capacity assessments had been developed for all people receiving care however the outcome or need for these assessments was not always clear.”
other
1 finding
moderate“Fire safety of the office location had not been monitored. Fire evacuation drills were not taking place.”
communication with families
1 finding
moderate“Some people may have benefitted from external input but this was not requested or recorded. For example, district nurse input in relation to diabetes management”
leadership
1 finding
moderate“A registered manager was in post at the time of the inspection however the support they had received from the franchise was minimal.”