minor“Staff did not always record the quantity of the dosage where the prescription offered this option.”
minor“where people required a number of tablets to make up a complete dose of the same medication, staff did not sign for each individual medicine. National guidance is that each dose must be signed for separately.”
staff training
2 findings
moderate“the provider had not always followed best practice guidance regarding the recruitment of staff from outside the UK in obtaining police reports from the country of origin.”
minor“Some people and relatives felt that some staff would benefit from additional training about always assuming people could consent to their care.”
record keeping
1 finding
moderate“staff had not always recorded the time they had administered medicines, or where the medicine had been applied on the person, such as a skin patch placed on top of the skin.”
care planning
1 finding
minor“there were some missed opportunities to identify improvements, such as the detail in people's care plans and risks assessments.”
staffing levels
1 finding
moderate“a number of people were dissatisfied when alternative staff arrangements were implemented... They felt they could not always rely on the service”
missed or late visits
1 finding
moderate“There had been missed care visits and alternative arrangements including community nurses and people's relatives meant there was minimal change to people's care.”
governance
1 finding
minor“Although not all incidents had been reported to us due to an internal communication issue... The registered manager now understood when we needed to be notified”
communication with families
1 finding
minor“not all people had been consulted where changes had been made. The provider confirmed that people or their relatives would be contacted to make sure any alternative arrangements had been effective”
staff competency
1 finding
minor“where staff had not been able to provide people's care or where some people felt staff weren't competent.”
complaints handling
1 finding
minor“Whilst alternative staff arrangements were in place, such as in unexpected staff absences, these were not always as respectful or effective as expected.”