Dolphin Healthcare - Wiltshire

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked at 2 quality statements in this category. We found there was a continued breach in safe. People were not always supported to identify and understand risks. Medicines were not always managed safely.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not always supported to identify and understand risks. This meant the provider could not be assured they were enabling people to do activities safely.

Staff we spoke to could identify how to safeguard people and who to speak to. They could also recognise different types of abuse they needed to be vigilant about. However whilst staff had reported safeguarding incidents, the provider had not always recognised the need to report these incidents to the local authority or the CQC.

There was no process in place to ensure the manager reported notifiable events to the appropriate authorities. People did not have appropriate risk assessments in place, 1 person did not have risk assessments for medicines that pose additional risks, this put people at risk of incidents.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us they were happy with how they were supported with their medicines. However during the assessment we saw people were not always supported safely with their medicines.

Staff told us they had been trained in medicine management but we found they were prompting one person medicines when there was no agreement or plan to do this. The provider was not aware that staff were prompting this medicine.

Systems and processes to ensure that people received medicines safely were not always followed or effective. Care plans sometimes lacked the necessary detail to support staff with managing peoples' needs. One person’s care plan stated staff were not supporting with medicines. However staff were prompting them to take medicines that had already been dispensed by someone else. This meant staff could not be assured the person was taking the correct medicine at the correct time which put them at risk. Another person’s medicine was managed between family and staff. At times their eMARs (Electronic medicine administration record sheet) was signed by staff. However in their daily notes at the same time staff had recorded family had given the medicine. This meant the person was at risk of harm by potentially being given double the prescribed dose of medication. As required (PRN) protocols (documents to support staff to know how and when to administer PRN medicine), were not in place to support staff in administering medicines consistently and as intended.