critical“MAR records did not always reflect all medicines people were prescribed... There was a risk medicines could be missed if MAR was not accurate.”
critical“Some MARs had different instructions to the medicine labels, on one occasion this had been discussed with the person but not their GP”
moderate“When paracetamol had been administered there was no record of the time recorded. This meant we were unsure if doses were sufficiently spaced with the required four-hour gap”
care planning
2 findings
critical“Risks were not always fully assessed and managed... the information was basic and required more details and personalisation to manage these.”
critical
“One record we reviewed had a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR)... However, there was no care plan or risk assessment to ensure staff had the guidance”
governance
2 findings
critical“Systems were not robust enough or established to ensure the oversight and good governance of the service. This placed people at risk of harm.”
moderate“The management team undertook regular monthly audits, however none of these issues had been noted which meant the audits were not effective.”
missed or late visits
1 finding
moderate“We received some feedback that visits were occasionally missed or late and people felt the service would benefit from more staff.”
staffing levels
1 finding
moderate“Careline (Community Careline services) is short of carers, if my regular carer can't come they don't let me know”
record keeping
1 finding
moderate“we reviewed some of the daily records returned to the service from people's homes... However, the records were dated from February 2022.”
person centred care
1 finding
moderate“they were brief and lacked person centred information to support and guide staff to meet the needs of people.”
communication with families
1 finding
moderate“If my regular carer can't come, they don't let me know. The office don't ring and they don't let you know”
leadership
1 finding
minor“There is a lack of management stability in the company.”
complaints handling
1 finding
minor“the records would benefit from more details about the concerns and the actions taken by the service. This would support improvements and lessons learned going forward.”
staff training
1 finding
minor“The training is all online. [There is] no face to face training, which is invaluable.”
incident learning
1 finding
minor“they would have benefited from more detail about the incident, and the incident had not been recorded on the incident log.”