moderate“We saw there had been four medicines administration and nine recording errors in the past 12 months.”
moderate“PRN medicines, protocols were in place. However these did not contain all the information needed, such as what the medicines were for, when the person might need it and the maximum dose.”
critical“Medicines administration records had limited information about the medicines, for example no dosage, route or times to be taken which could result in people not receiving their medicines as prescribed.”
moderate“there had been a medicine's incident at the service...the registered manager stopped staff administering medicines until they were re-trained.”
record keeping
3 findings
moderate
“We found where people were receiving support with their medicines, risk assessments were not in place.”
moderate“We found the service did not have all the details of where a person had a LPA and this was not consistently recorded in people's care records.”
moderate“For some people there had been incidents, such as choking or falling where associated risk assessments had not been completed.”
governance
1 finding
critical“The registered manager did not notify the CQC of important events, such as when the Police was contacted or a Deprivation of liberty safeguard had been authorised.”
care planning
1 finding
moderate“Care plans were not always person centred but more task orientated... There were no details of how the person preferred to have their care done or if they preferred a male or female carer.”
communication with families
1 finding
minor“People and their relatives told us they weren't always informed when a carer was running late. One person said 'No, they don't often let me know if they are late'.”
person centred care
1 finding
minor“Care plans did not include information on people's specific wishes, preferences, likes or dislikes around aspects of their life other than personal care.”
incident learning
1 finding
critical“the service had not notified us of incidents they were legally required to. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”