critical“Medicines were not always given safely or as prescribed.”
critical“One person's medicines were not given at the prescribed times and staff had not understood that these medicines were time sensitive.”
governance
1 finding
critical“Medicine audits did not follow good practice guidance. Medicines records were sometimes amended up to a week after the care visit had taken place.”
record keeping
1 finding
moderate“On occasion staff were asked to confirm if medicines were given several days after the medicines should have been administered”
staff competency
1 finding
moderate“References were not always checked enough to ensure they matched application forms, were valid or were from the most appropriate source.”
missed or late visits
1 finding
moderate“some calls were still happening outside of the agreed times and sometimes over an hour late.”
staffing levels
1 finding
moderate“I am getting new people some of the time, not all of the time. I get them and then I don't see them for weeks. There's quite a few different carers.”
staff training
1 finding
moderate“staff did not always have the right skills for the person, such as knowledge of dementia, and some commented that they had communication difficulties with some staff.”
care planning
1 finding
moderate“Some risk assessments, however, did not give clear or consistent details, for example about people's diets or in relation to medicines they were taking.”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality care.”