minor“Due to the two methods of recording, it was not always clear to see what medicines had been given and when.”
critical“MAR charts did not always contain details such as what time a medicine should be taken or how many tablets to take. In one case, the name of the medicine was not present.”
record keeping
2 findings
minor“The provider told us that two systems were being used to monitor the giving of medicines as a temporary method.”
critical“One person whose care plan stated they needed staff to prompt them with medicines did not have a MAR and staff were not recording in daily notes whether they prompted the person.”
care planning
1 finding
moderate“Some of the information in care plans was out of date or incomplete...one person's care plan referred to what they would like to happen when they came out of hospital, which had already happened.”
consent capacity
1 finding
critical“None of the three people whose care plans we reviewed had provided a signature or other indication that they consented to their care being provided as planned.”
governance
1 finding
moderate“The provider's audits and checks were not always effective in identifying improvements that were required. Their care plan audits had not identified the problems we found.”
safeguarding
1 finding
moderate“Staff did not always know the correct procedures to follow when reporting a safeguarding concern. Two staff told us they would discuss the concerns with people or their relatives.”
cultural competency
1 finding
minor“Although the provider asked about people's diverse characteristics such as cultural and religious needs...it was not always clear whether these were considered when planning people's care.”
end of life care
1 finding
moderate“One care plan also made reference to a decision not to attempt resuscitation in the event of cardiac arrest but there was no evidence to show this decision had been made by an appropriate medical professional.”
staff training
1 finding
minor“The service did not have a written accident and incident reporting policy in place. This meant there was a risk that the provider's system would become less effective as the service expanded.”