moderate“The audit system had not identified the lack of detail in people's records.”
minor“We saw that the medicine policy did not include reference to the current best practice guidance.”
medication management
2 findings
moderate“Improvements were needed to some medicine records and the medicine audit. Staff were transcribing the medicine administration records for people. We found these did not always contain all the information about medicines.”
moderate“The audit system had not identified that PRN protocols... were not in place. Audits had identified that appropriate gaps had not been left between the medicine for one person.”
record keeping
1 finding
moderate“People's assessments and care plans did not contain all the information staff may need to provide care. For example, in relation to skin integrity, diabetes care and catheter care.”
communication with families
1 finding
minor“Some people told us they did receive a rota but it did not always arrive on time.”