minor“where they had been highlighted it was not always clear from the audit what action had been taken to follow any concerns up with the care worker.”
critical“instructions on one box were for the tablet to be dissolved on the tongue. However, the MAR instructions stated the tablet should be "dissolved in a little water."”
critical“MARs usually only identified the giving of tablets from the dossette box as a number and not the individual medicines contained within the dossette box.”
missed or late visits
2 findings
moderate“staff told us travel between appointments could still be an issue and they continued to sometimes 'pinch a few minutes here and there.'”
moderate
“no travelling time factored into their schedules... often delayed in getting to calls later on the list.”
record keeping
2 findings
minor“whilst old documentation was stored at the rear of files, it was not always clear that a review had taken place.”
critical“Systems were not in place to maintain an accurate, complete and contemporaneous record in respect of each service user. Regulation 17(2)(c)”
care planning
2 findings
critical“care plans sometimes lacked detail or did not reflect the type and range of care that was being provided.”
moderate“one person's care plan we saw written the word's "Catheter care", with no explanation as to what action the care worker should take.”
staffing levels
1 finding
moderate“One supervisor told us that in previous weeks they had worked their normal supervisory role and undertaken an additional 32 hours care work to support care delivery.”
staff training
1 finding
minor“the majority of training was undertaken using workbooks...Staff said this type of training did not always cover the practical aspects in good detail.”
consent capacity
1 finding
minor“Staff told us they could not recall receiving specific dedicated training with regard to the Mental Capacity Act 2005.”
governance
1 finding
moderate“no registered manager in place at the service, although our records showed that a person was still registered with the Commission.”