critical“MAR stated to administer 1 tablet of a medicine twice daily; instructions also said to administer half a tablet of this medicine twice daily.”
moderate“Staff received training in safe management of medicines, they were not assessed to ensure they were competent to administer medicines.”
missed or late visits
2 findings
critical“On 1 occasion their relative did not receive their first care visit until 12:20pm when this should have taken place between 9:30am and 10am.”
moderate“For 33% of the calls, staff had no travel time which could have affected call punctuality...a significant number of short and/or late calls.”
governance
2 findings
critical“Management audits were not robust enough as they did not reveal the shortfalls we found in relation to the safe management of people's medicines.”
moderate“They did not have a clear improvement plan in place to demonstrate the steps they were planning to take and details of any timescales.”
care planning
1 finding
critical“One person was at risk of choking due to dysphagia...the service had not requested for specialist support from a healthcare professional to ensure the person received a comprehensive swallowing assessment.”
staffing levels
1 finding
moderate“4 out of 8 care workers commented on the lack of travelling time to get from one person to another.”
incident learning
1 finding
moderate“A staff survey carried out by the service in June 2022 revealed the difficulties staff faced...Suggestions from staff which had not been acted upon at the time of the inspection.”