moderate“We did however find some discrepancies in MAR charts and care plans relating to medicines...discrepancies relating to dosage.”
moderate“Protocols were not in place for PRN (as required) medicines. This is important to ensure they are given consistently and appropriately by staff.”
moderate“for some MAR charts that had been hand-written by staff, these had not, and improvements were required in order to mitigate possible medicine errors or misadministration.”
moderate“we did identify some care plans where people's list of current medicines needed updating.”
governance
2 findings
critical
“Systems and processes did not always identify areas where quality and/or safety were being compromised. Regulation 17 HSCA RA Regulations 2014.”
moderate“for one person's MAR charts we saw that the auditing system had failed to identify several concerns where practice and recording had failed to meet good practice guidance.”
record keeping
2 findings
moderate“Auditing processes had failed to identify some issues we found with documentation including medicines.”
minor“We found an employment gap for one staff member and this was brought to the registered manager's attention who acknowledged a full employment history was required.”
care planning
1 finding
critical“Some risk assessments did not contain relevant guidance for staff in how to mitigate risks. Regulation 12 HSCA RA Regulations 2014.”
person centred care
1 finding
moderate“Information contained within them was often too brief, and did not reflect a person-centred approach.”
end of life care
1 finding
moderate“Care plans relating to people's end of life wishes were brief in content. Some just stated that they had a funeral plan.”
consent capacity
1 finding
minor“Further improvement was needed where people were living with dementia, so their care plans were clear about what decisions they were still able to make.”
staffing levels
1 finding
minor“Ten people we spoke with commented on the number of different care staff who visited them...this did leave them feeling unsettled.”
incident learning
1 finding
moderate“incidents where medicines had gone missing from people's homes. We saw that appropriate action had been taken in response to these incidents although the service could have taken more robust action in one case.”