critical“1 person was prescribed medication to be taken before food. We saw staff were providing this medication after food which meant there was a risk the medicine would not be effective.”
critical“Staff had not received any medication competency checks or assessments.”
care planning
2 findings
critical“one person was at risk of falls from their chair, but there was no risk assessment in place to identify this risk or provide an action plan for staff to follow.”
critical“one person had returned from hospital with significant changes to their pressure area care. There was no short-term care plan in place.”
consent capacity
2 findings
critical“a decision had been made for limitations to be placed on food and drink accessibility within their home. There was no best interest decision or consent documented in their care file.”
moderate“Some staff had not completed their MCA training and other staff who had could not describe their understanding of the principles of the MCA.”
governance
1 finding
critical“Governance systems were not effective and in some instances were not in place. This resulted in a lack of oversight for medication, risk assessments, call monitoring, complaints, accidents and incidents.”
incident learning
1 finding
moderate“There was no evidence of lessons learnt as the providers system for recording near misses and low-level accidents was ineffective.”
record keeping
1 finding
minor“care records did not show clearly where other professionals had been contacted to ensure people's health needs were met. District nurses and GP contact was not captured in the documentation.”
complaints handling
1 finding
moderate“Complaints and concerns that had been raised were not robustly documented or monitored for patterns or trends to improve the service.”