moderate“the provider's audits had not identified the issues we found at this inspection in regard to information that was missing from one person's environmental risk assessment”
moderate“provider's quality audit had not picked the concerns we identified in relation to one person being administered a weekly pain relief patches by staff member.”
minor“no communication record to show that the office staff had informed people when staff were running late to their scheduled home visits and this required improvement.”
medication management
2 findings
moderate“there was no guidance for staff on the circumstances in which administration may be required, the maximum dose, or the frequency at which the medicine could be safely administered”
moderate
“medicines administration record (MAR) and medicines care plans did not include information about this prescribed medicine, the dose required and the frequency of administration.”
record keeping
2 findings
moderate“action was not always promptly taken to ensure people's care plans and risk assessments were updated where their conditions had deteriorated”
moderate“provider had not kept records to monitor the nature of out of hour's calls to see if there was any pattern and to improve the quality of the services people received.”
care planning
1 finding
critical“risks to people were not always adequately assessed and there was not always detailed guidance in place for staff on how they should manage identified risk safely”
missed or late visits
1 finding
moderate“office staff had not always allowed enough time for staff to travel between calls when taking into consideration the distance between two home visits, the mode of transport.”