critical“MARs did not always include a record of what individual medicines looked like from people's medicine blister packs, therefore staff have limited guidance to identify what medicines they were administering.”
moderate“The service was not following the provider's medicine policy in relation to 'as required' medicines.”
governance
2 findings
critical“The service did not always make statutory notifications to the CQC when required.”
moderate“Medicine audit systems were not robust. 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.”
record keeping
1 finding
moderate“Records to show topical preparations such as creams were not always completed; therefore, we were not assured people's skin was cared for properly.”
consent capacity
1 finding
moderate“The provider had no specific mental capacity assessments in place. The registered manager implemented mental capacity assessments during the inspection process.”
end of life care
1 finding
minor“Care plans did not consider people's end of life wishes.”
staff training
1 finding
minor“Staff had not received specific training in relation to one person's modified dietary needs.”