moderate“At the last inspection carried out in March 2018 we found the registered manager had failed to manage medicines in line with their policies and procedures.”
critical“We found people did not always have medicine support plans in place which contained an up to date medicines list. We found one person had no record of the medication they were prescribed.”
critical“Medicines audits we checked had not picked up on issues we found such as missed signatures and signatures that had been scribbled out.”
moderate“the MAR chart for this person did not identify the type of medication patch, the strength of the medication or how often it needed to be replaced and some signatures were missing.”
record keeping
3 findings
minor
“people who used bed rails and bed levers did not have risk assessments. By the end of the inspection, assessments to manage risk had been completed.”
moderate“Daily notes for the person did not document where the patch was applied to ensure this was done safely.”
moderate“The MAR charts contained hand written entries, but these had not been signed, witnessed or countersigned, in order to reduce the possibility of medications being transcribed incorrectly.”
care planning
3 findings
moderate“At the last inspection carried out in March 2018 we identified care plans were inconsistent and did not always have enough detail, considering the complex needs of the individual.”
critical“Risk assessments we looked at did not always contain information to adequately lessen the risks to individuals. One example was for a person who had diabetes type 2. The risks and plans to manage the risk were not recorded.”
moderate“We found care plans were inconsistent and did not always have enough detail, considering the complex needs of the individual cared for.”
consent capacity
2 findings
minor“At the last inspection in March 2018 we made a recommendation regarding the signing of consent forms and recommended that any discussions and outcomes regarding consent were documented appropriately.”
moderate“We found people's capacity to consent to care had not always been assessed and information was, at times, conflicting.”
missed or late visits
1 finding
minor“Sometimes as the rota says unallocated you don't know who if anyone is going to turn up and they don't always arrive on time.”
governance
1 finding
critical“The audit system had not identified the breaches of regulation and areas of improvement we had noted during this inspection.”
staffing levels
1 finding
minor“two relatives told us they thought there had been a staff shortage for a few weeks recently, which had resulted in unfamiliar care staff arriving and more than the usual number of late calls.”
person centred care
1 finding
minor“two males...told us they preferred male care staff to deliver their personal care, but due to a shortage of male care staff this was not always possible.”
communication with families
1 finding
minor“three people told us they did not think the communication with the office staff was good. For example, messages were not always passed on.”
staff training
1 finding
minor“the training matrix we saw showed that some training modules were slightly overdue, but this had been recognised by the registered manager and efforts were being made to ensure all training was brought up to date.”