critical“Medicines were not stored securely. Medicines were kept unlocked, in a kitchen cupboard.”
critical“A PRN medication had been administered frequently. This was not in line with the prescriber's instructions, placing the person at potential risk of harm.”
moderate“gaps were identified on the MAR chart and staff were unable to clarify why there were gaps.”
record keeping
2 findings
moderate“People's medicines records were not always collected regularly from people's homes and this meant the management team were not able to review them.”
minor
“a daily catheter care record for one person was not in place.”
governance
1 finding
critical“Call time audits did not identify the shortfalls we identified at this inspection. The current system was unable to identify the shortfalls identified at this inspection.”
missed or late visits
1 finding
moderate“Our analysis identified 25% of people's care visits lasted less than half the agreed duration. There were 186 pairs of calls where staff had logged in at 2 locations simultaneously.”
communication with families
1 finding
moderate“Not all people or those acting on their behalf felt the service's communication arrangements were effective. One person told us, 'I would give them a 5/10.'”