moderate“concerns were that some people who were supported by the service did not have a prepared list of their medicines in the home and may also have large stocks of medicines in the home”
critical“gaps in Medicine Administration Records (MAR) where records had not been completed...unclear which inhaler had been administered”
critical“PRN (as required medicines) protocols were not in place...one person prescribed a strong pain relieving medicine...instructions 'as required'”
record keeping
2 findings
minor“improvements were required in the completion of the medicine administration records (MARs). This included the information recorded if people needed assistance with applying creams and topical medicines”
critical
“number of times the strong pain relieving medicine was administered...on only five occasions was the time of the administration recorded”
governance
1 finding
critical“no effective governance systems in place to prevent the medicine shortfalls found at this inspection...quality monitoring systems in place were not effective”
missed or late visits
1 finding
critical“one person's care record we found that they had not received their daily morning visit...not noted until some 24 hours later”
care planning
1 finding
moderate“care plans lacked detailed information to reflect personalised support...one care plan simply stated 'assistance required'”
supervision appraisal
1 finding
moderate“staff supervisions had not been undertaken as often as directed by the provider's supervision policy”
staff training
1 finding
minor“people using the service who lived with dementia. Specific training for staff to meet people's needs is good practice”
consent capacity
1 finding
moderate“Staff we spoke with had variable knowledgeable about the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards”
person centred care
1 finding
moderate“care plans across the service were not personalised and did not contain unique individual information and references to people's daily lives”