critical“Records showed people's Medicines Administration Records (MAR) had gaps and omissions, and staff had failed to use the key codes to explain as to why the medicines had not been administered.”
record keeping
1 finding
critical“People's MARs did not always contain the medicines dose, route or frequency for administration. This meant people were at risk of receiving their medicines at the incorrect time.”
staffing levels
1 finding
moderate“Two staff members had worked 30 consecutive days between the 1 August and 31 August 2022. The extensive days worked by staff members meant there were not enough staff deployed.”
governance
1 finding
critical“The provider had not developed robust governance systems to ensure the oversight and monitoring of the service was effective. Auditing systems failed to identify some of the issues found.”
incident learning
1 finding
moderate“Incident and accident records were not clear or specific in confirming the action taken following incident occurrence, or that learning was shared.”
care planning
1 finding
moderate“Care records were not always as personalised as they could be to reflect people's preferences. These did not contain enough information on people's preferences.”
end of life care
1 finding
minor“People's end of life care wishes were not always clearly recorded. There was not always clear guidance or a record that people had declined to discuss their end of life preferences.”
leadership
1 finding
critical“At the time of the inspection, there was not a registered manager in post. Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people.”
person centred care
1 finding
minor“People's independence was not always promoted as well as it could be. Whilst care records stated whether people wished to remain independent there was no clear guidance.”