critical“staff were signing for medicines that had actually been administered by another member of staff. After we brought this to the registered manager's attention they took steps to ensure this ceased with immediate effect.”
moderate“There had been five medicine incidents when a person had not received all of their medicines...only the second incident had been reported to the person's GP.”
incident learning
1 finding
moderate“staff had failed to consistently follow guidance and check with the prescriber if there was a potential impact for people.”
record keeping
1 finding
minor
“these audits and resulting actions were not documented, which would have demonstrated which files had been audited and what actions had been taken.”