critical“One person had not been receiving the correct dose of their medication for several weeks. The error was noticed however, no action was taken to safeguard this person, such as informing their GP.”
critical“Time specific medicines were not always adhered to, for example one person was prescribed pain relief 12 hours apart...resulting in a risk of overdose or poor pain management.”
care planning
2 findings
critical“Some people using the service did not have a care plan in place. This meant there was no information to guide staff on how to safely care for people.”
moderate“We reviewed 2 people's mobility care plans and found them both to hold conflicting information on how to safely assist people with their mobility.”
missed or late visits
1 finding
moderate“Staff regularly did not stay for the full length of the call...They are supposed to have a half hour visit but they are here for about 20 minutes.”
governance
1 finding
critical“Governance systems were not always effective. Audits had not identified the issues we found during our inspection.”
safeguarding
1 finding
moderate“We did find incidents where safeguarding concerns were not always reported in a timely manner.”
record keeping
1 finding
moderate“There were gaps in some people's medication records with no explanation.”
staffing levels
1 finding
moderate“Visit durations were not being monitored and addressed when short in duration. Feedback from people raised concerns around visits not lasting the full length of time.”