critical“Exact timings for when medication needed to be administered were not recorded on the MAR Chart. They had been recorded as 'morning' and 'evening'.”
critical“A person was given an additional dose of medication and this was not identified during the registered manager's audit.”
governance
2 findings
critical“Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough. This was a breach of Regulation 17.”
moderate“Audits were ineffective and not reviewed regularly. The manager's audits had failed to identify the concerns we found with the management of medicines and staff recruitment files.”
care planning
2 findings
moderate“The care plans did not contain a picture of the person, their likes, dislikes or their medication details. No information was available about people's life history.”
critical“1 person who was at risk of choking did not have a choking risk assessment in place which meant staff would not know how to support the person.”
record keeping
1 finding
moderate“A person was prescribed with a cream which needed to be applied regularly, however, this was not recorded on the MAR Chart.”
staff competency
1 finding
critical“Relevant recruitment checks were not always completed before staff started work. We saw gaps in recruitment files, such as incomplete application forms and no interview notes.”
end of life care
1 finding
minor“There was limited information in the support plans we reviewed relating to people's end of life wishes.”