critical“Staff did not routinely comply with the service's medicine policy or with the local authority medication policy.”
moderate“Staff had not been competence assessed in their administration of medicines or recording practices.”
safeguarding
1 finding
critical“None of the medicine errors we discovered had been referred to the Local Authority Safeguarding team. The registered manager was unaware this was a Local Authority requirement.”
record keeping
1 finding
moderate“Care files demonstrated a lack of detail provided about the identified risks people faced and how these should be mitigated.”
governance
1 finding
moderate“There was an absence of regular, documented auditing of medicine administration and records, visit sheets and communication logs.”
consent capacity
1 finding
minor“There was a lack of information to support this. The care plan also required more detail to explain how staff could support a person who lacked capacity.”
staff competency
1 finding
minor“Medication competence assessments and care observations should be routinely undertaken and recorded.”
end of life care
1 finding
minor“Care files we reviewed did not contain specific information relating to end of life care or wishes.”