critical“People's medicines records did not always contain enough detail. The service used electronic medication administration records (MARs) and they lacked detail of the medicines administered from blister packs.”
critical“People's allergies were not recorded.”
governance
1 finding
critical“Although a medicines audit tool was in place and being completed regularly it did not pick up on the discrepancies we found during the inspection.”
leadership
1 finding
moderate“The provider had poor management systems in place to support oversees staff with their employment at the service. Staff told us about various issues with their employment and contracts.”
end of life care
1 finding
moderate“Care plans did not consider people's end of life wishes. We fed this back to the provider, who told us they would take action to ensure people's end of life wishes would be discussed.”
communication with families
1 finding
minor“People told us staff were on time for their visits, however, when staff were delayed, people were not always informed.”