critical“Medication audits had taken place which identified a large number of medication record keeping and administration errors. These included gaps in the MAR due to codes not being written down, medication not being given and miscounts.”
care planning
1 finding
critical“People's records did not have detailed plans on how to manage their risks. This was for things such as seizures, catheter care and for smoking, which put them at increased risk of harm.”
governance
1 finding
critical“Systems had not been established to robustly monitor the quality and safety of care provided. This was a breach of regulation 17(1) of the Health and Social Care Act 2008.”
record keeping
1 finding
moderate“Not all audits were in place including care plan audits which meant care records were not reviewed to identify gaps in risk management and care plans.”
incident learning
1 finding
moderate“Records for incident management and lessons learnt was not robust and clear to show what actions were taken from specific incidents and that the care records were updated.”
consent capacity
1 finding
minor“The care records were not detailed to include information on authorisations for people who had appointed others to make decisions on their behalf under the MCA.”
staff competency
1 finding
moderate“Recruitment systems were not robust as not all the appropriate checks had taken place. We found gaps in employment history, inconsistencies in interview records and no right to work documents.”