minor“we found the details could be further improved to ensure people who were unable to verbally consent were supported by staff who had additional guidance on when the medicine should be given”
moderate“A senior office member of staff undertook a medicine review; however these did not always pick up omissions on the MARs.”
minor“Where medicine administration was shared with family member it was not always clear which dose was administered by whom.”
critical“We found prescribed medicines were not always routinely listed on MARs. For instance, antibiotics and eye drops had been administered by staff, without any written guidance on the MAR.”
governance
2 findings
minor
“It did not always use information gathered at reviews to drive improvement.”
moderate“The provider's governance systems had not identified the service was not routinely following national guidance with respect of safe medicines administration.”
care planning
1 finding
minor“we found some guidance for staff had been omitted with this change... more in-depth detail was required to ensure the person's safety”
consent capacity
1 finding
minor“Care workers we spoke with were unable to fully provide us with their understanding of how it affected the way they worked with people.”
record keeping
1 finding
critical“We found no MAR chart in place for one person for a period of six days. Daily records showed care workers had administered prescribed medicines to the person for the same period.”
end of life care
1 finding
minor“We observed end of life wishes had not been recorded in people's care plans. This meant people may not have been given the opportunity to discuss their end of life needs and preferences.”
leadership
1 finding
moderate“At the time of the inspection there was a manager registered with the CQC, however they were no longer in post and an application to remove them was being processed.”