moderate“five people's MARs contained gaps with no explanations for them or had missing information on them such as role of transcriber, doses of medicines not signed for”
minor“the medicine audits did not identify the gaps in the MARs we found they did not have codes on them to explain the reasons for the gaps in these records.”
record keeping
1 finding
moderate“Checklists for tracheostomy, ventilator, weekly equipment changes, hourly ventilator observation charts and ventilator temperature checks were not always recorded as required.”
staff competency
1 finding
moderate
“Sometimes they take care workers who don't know how to use the hoist or do things...individual staff competencies were not met following training in the safe use of equipment.”
staffing levels
1 finding
moderate“They cancel shifts at very short notice...The other two days are always cancelled because they struggle to find carers”
governance
1 finding
moderate“There was a system for reviewing people's MARs but it did not identify the issues we found with the inconsistencies of recording.”