critical“The provider did not always ensure care workers were provided with appropriate guidance to ensure medicines were administered as prescribed.”
critical“the visit in the morning occurred over one hour after the time indicated on the MAR chart. There was no guidance for care workers in relation to the importance of administering the time specific medicines as prescribed.”
care planning
1 finding
critical“If the provider identified a specific risk which could be related to a person's health, wellbeing or care needs, a risk management plan had not been developed for care workers providing guidance”
governance
1 finding
critical
“The provider did always have systems in place which were robust enough to enable them to identify where action was required. This was a breach of regulation 17(1)”
record keeping
1 finding
moderate“We saw one person's care plan had not been updated to reflect a change to how their care was provided which had occurred in November 2021.”
consent capacity
1 finding
moderate“the provider had not undertaken a mental capacity assessment to identify if the person had the capacity to make decisions about their own care.”