critical“The management of medicines did not ensure people received their medicines as prescribed, placing them at risk of harm. This is a breach of regulation 12.”
critical“Prior to our inspection visit 1 relative had raised concerns that a medicine that had no longer been prescribed, had been administered to their relative.”
missed or late visits
1 finding
moderate“Five out of 13 people we spoke with told us they had experienced a missed call. One person told us their night call had been missed and they had to go to bed in their day clothes.”
consent capacity
1 finding
critical
“One out of 8 members of staff we spoke with was unaware of the Mental Capacity Act, 3 members of staff did not have a clear understanding.”
governance
1 finding
critical“The provider's governance was ineffective to ensure all staff had access to relevant training or to adapt the principles of the mental capacity act. This is a breach of regulation 17.”
staff training
1 finding
moderate“Staff had not received training in these areas. For example, the provider offered a service to a person who had a diagnosis of epilepsy and another person who was receiving end of life care.”
end of life care
1 finding
moderate“There was no evidence staff had received end of life training. A senior care staff told us staff watched a DVD on death and bereavement.”
complaints handling
1 finding
moderate“The registered manager did not apologise to the complainant and care and support was withdrawn. Hence, the principles of the duty of candour had not been applied.”
communication with families
1 finding
minor“People told us when they telephoned the office about a call being late or missed, swift action was taken. However, no one from the office had contacted them to say the call would be missed.”
record keeping
1 finding
critical“Vital information relating to people's prescribed medicines were not contained in their records, placing them at potential risk of harm.”