moderate“PRN medicines were not listed on the MAR chart or list of current medication in one person's care plan. A PRN protocol for one medicine had not been completed fully.”
governance
1 finding
critical“audits had failed to identify the concerns we found relating to safe staff recruitment, care plans, medicine records and risk assessments.”
care planning
1 finding
moderate“even though a person had been assessed as 'at risk' of potential skin integrity concerns, documentation had not been implemented to guide staff on how to identify and manage those risks.”
record keeping
1 finding
moderate“incorrect timings were transcribed on the MAR chart...The MAR did not include any specific instructions, no medicine stop/review date, and some medicines were spelt incorrectly.”
staff competency
1 finding
minor“Staff had received training in the MCA and Deprivation of Liberty Safeguards (DoLS), however, staff's knowledge was variable.”
staffing levels
1 finding
moderate“The registered manager had not ensured safe recruitment practices were being followed...not all employment references had been verified, references for conduct in previous health and social care employment hadn't been asked for.”