critical“One person using the service was prescribed with controlled medicines patches. However, rotation of the patches were not recorded by the service provider.”
critical“we saw a recent medication error where an agency staff member administered diabetes medicines to a wrong person.”
critical“one person refused their diabetic medicines four days in a row. There was no information on how this might affect the person's health and well-being. There was no evidence of staff contacting the person's GP or 111.”
care planning
2 findings
critical“Another person had Type 2 diabetes and required medicines, but these were not detailed in the person's care plan. This information was also missing in the person's hospital passport”
moderate
“Some people's care plans were out-of-date or did not contain important information regarding their health and well-being.”
record keeping
1 finding
moderate“Records related to people's care were not always accurate or up-to-date.”
governance
1 finding
moderate“Governance processes were not always effective in identifying shortfalls. For example, we found areas for improvement in care planning that were not identified prior to our inspection.”
staff competency
1 finding
moderate“We were not reassured that staff, agency staff in particular, understood the person's condition.”
staffing levels
1 finding
minor“some people told us that due to the funding they felt restricted by low staffing numbers.”
leadership
1 finding
moderate“the success of this approach had been affected by changes in leadership at the service and the high use of agency staff.”
communication with families
1 finding
minor“I don't receive any phone calls, letters or emails from them, I don't feel I am kept up to speed on medical issues”