critical“staff had not always completed the MAR correctly by signing each time they administered medicines or entering a code if for any reason people did not take their medicines.”
critical“Lorazepam 1mg tablets...had been left along with other medicines and creams on the unit top in the kitchen area of their apartment. They were not recorded on the MAR.”
minor“Records did not always indicate where, why and how these should be administered. One bank staff member told us, "The only thing I raised is the body charts. In terms of knowing where to put specific creams."”
governance
1 finding
critical“although the shortfalls in the medication system had been identified by the organisation prior to the inspection no action had been taken to ensure people received their medicines safely.”
incident learning
1 finding
moderate“[Name of registered manager] was alarmed by the number of med errors they were coming across...dates still not being put on creams, eye drops and Paracetamol not in original containers.”
leadership
1 finding
moderate“the registered manager had also failed to escalate concerns to the senior management team to allow them to support the process of addressing shortfalls in medication practices.”
record keeping
1 finding
minor“we found some daily reports lacked detail about the level of care and support provided...no formal process in place for daily records once completed to be returned to the office for audit purposes.”
end of life care
1 finding
minor“The registered manager told us they were aware this was an area for improvement and we saw documented evidence of people's future wishes was not completed in most people's care records.”
staffing levels
1 finding
minor“We have at times been very short staffed. We've worked through that. We're not consistently short staffed. We do have bank staff; we could really do with building that up.”