critical“People's allergies were not recorded on the handwritten MAR sheets. This meant that people could be put at risk of being given medicines they were allergic to.”
critical“medicine patches were not being administered in line with manufactures instructions to rotate the patch. There was no evidence that staff were checking regularly that the patch was still in place.”
care planning
1 finding
moderate“People were not always supported safely to reduce their risk of pressure ulcers... There were no risk assessments in place to help manage risks in relation to pressure ulcers.”
staff competency
1 finding
moderate
“Agency staff had an introduction to the home via an induction but the service manager had not ensured competency assessment had been completed.”
staffing levels
1 finding
moderate“There was a high level of agency staff being used at one home... agency staff were not insured to drive these cars. This led to people not having as high a quality of life.”
governance
1 finding
moderate“audits had not identified the issues we found on inspection in one home around medicines. There was less oversight of the handwritten records.”
record keeping
1 finding
moderate“One home had handwritten Medicine Administration Records (MAR) due to the high level of agency staff who could not access their electronic medicine records (E-MAR) system.”
consent capacity
1 finding
minor“The provider had not always recorded they had consulted and involved people in decisions, such as choices around healthy eating.”