critical“In total there were three possible systems in place for staff to use to record the administration of medicines. This was potentially confusing and made it difficult to establish what medicines people had received and when.”
moderate“Due to IT issues the electronic MARs were not always completed to indicate people had received their medicine... it was not possible to evidence clearly when people had been supported with their medicine.”
record keeping
2 findings
critical“The provider had failed to maintain accurate, complete and contemporaneous records in respect of each service user in relation to medication.”
moderate“We looked at one person's MARs in both formats and found there were several discrepancies between the two.”
governance
2 findings
moderate“Managers completed audits of the service, including medicines audits...However, the processes introduced to rectify the issue had not been effective.”
critical“Audits and checks of the service were carried out. However, these had failed to identify, or address, the shortcomings found at inspection.”
care planning
2 findings
critical“Some people were at risk associated with their specific health condition. There were no care plans or risk assessments in place to guide staff on how to support people in this area.”
critical“one person had an oxygen supply in their home which can be a fire hazard. There was no associated care plan or risk assessment in place.”
staff training
2 findings
critical“out of 16 staff only four had completed food hygiene training, five had completed dementia training and four had completed training for personal care.”
critical“only two members of staff had completed training in either of these subjects [end of life care and the Mental Capacity Act].”
staff competency
2 findings
critical“Recruitment systems to help ensure staff were suitable to work in the care sector were not robust. The application form did not require applicants to give an employment history or provide explanations for any gaps in employment.”
critical“One member of staff, who had been working at the service since July 2022, only had one reference on their staff file; this was from a past employer where the applicant had worked in 1999.”
missed or late visits
1 finding
moderate“There had been a recent event when a visit was missed. This had occurred after the visit had been reallocated due to staff sickness and the staff member newly assigned to the visit had not picked up the message.”
person centred care
1 finding
minor“People's paper care records did not contain details about people's preferred routines and the support they required at each visit.”