critical“The service was running on 35 full time vacancies at the time of inspection. Staff had been asked to work when on annual leave and on days off.”
medication management
1 finding
critical“Transcribed medicine administration records (MAR) had not been signed by two staff to ensure the information recorded was identical to the prescribed dose.”
care planning
1 finding
critical“One person had conflicting information recorded regarding how much thickener was required to mitigate the risk of choking. This put the person at risk of aspiration.”
governance
1 finding
critical“The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
record keeping
1 finding
moderate“Staff had not recorded the duration, time or presentation for one person who had experienced three recent seizures.”
person centred care
1 finding
moderate“People did not always know what staff were coming to support them or the times they were coming. 'They don't tell me when they are going to turn up.'”
incident learning
1 finding
moderate“Not all risk assessments had been updated or reviewed after an incident. One person's falls risk assessment had not been updated after the person had fallen.”
missed or late visits
1 finding
moderate“Due to the lack of staffing some calls had to be cancelled, reduced or times changed. A person was not able to return home after a hospital admission.”