critical“Medicines Administration Records (MAR) did not always provide sufficient information to enable the safe administration of medicines and documentation of medicines administered was not consistently completed.”
critical“MAR were not always consistently completed and where instructions on how to administer medicines had been available it was not always clear these had been followed.”
moderate“PRN medicines were not always managed effectively. There was not always an indication given on the MAR to state what the maximum daily dose of this medicine should be.”
critical“At our last inspection on 1 August 2016 we identified concerns relating to medicines management. These concerns were a breach of Regulation 12 of the Health and Social care Act 2008.”
record keeping
1 finding
moderate
“All MAR had been handwritten... the MAR should be signed by a Home Instead Senior Care employee to confirm the handwritten details matched those printed on the blister pack or label on packaging. However, this was not always done.”
consent capacity
1 finding
minor“Some consent forms had been signed by a next of kin or relative. In some cases, there was a record that the person had a legal right to do this on a person's behalf but this was not consistent in all care files.”
staff competency
1 finding
minor“Although staff received supervisions and had competency assessments recorded during their induction, there was no record available to confirm the assessment of competency in certain areas had been completed as part of their regular supervisions.”