minor“some 'as required' medicine protocols were not detailed...not clearly stated in their care plans. The provider took immediate action at the time of inspection”
critical“The MAR stated D Box and did not list which medicines were to be administered. People did not have a medicines profile in place.”
critical“MARs did not always contain details of topical medicines and people's care records did not always contain enough information to advise staff of where and when topical creams should be applied.”
critical“Where people were administered medicines from a dosset box there was no breakdown of the individual medicines on the MAR sheet.”
moderate“Protocols were not in place detailing when staff should offer 'as required' medicines. This did not support safe and consistent practise.”
governance
4 findings
critical“Concerns we identified with medicines administration records should have been identified through a robust system of checks.”
moderate“There were none in place for areas such as call logs, daily notes, service user surveys, complaints, accidents and incidents.”
critical“monthly medication audits were in place, but they had not been effective.”
moderate“we reviewed medication checks we identified gaps in signing and inconsistencies which had not been identified through audit”
record keeping
3 findings
minor“We highlighted it would be beneficial if all action taken as a result of audits was clearly recorded. This provides an audit trail and clearly demonstrates issues identified have been actioned.”
moderate“Staff had only recorded what food had been provided to the person but not what they had eaten. This meant that the person's risk of malnutrition was not being appropriately monitored.”
moderate“Hand written information on MARs was not always clear and legible.”
incident learning
2 findings
minor“analysing trends and patterns which could reduce risks required review. The registered manager and nominated individual took immediate action to address this.”
moderate“More work was required to demonstrate that investigations were thorough and comprehensive and lessons learned were reflected on and communicated.”
care planning
2 findings
moderate“Care plans were not always person centred and did not contain information about people's preferences and how they wanted their care to be delivered.”
moderate“One person's needs assessment stated they lived with epilepsy. There was no care plan or risk assessment to reduce the risks associated with this.”
safeguarding
1 finding
moderate“following a recent investigation, they have acknowledged lessons learnt and understand the need to escalate concerns.”
complaints handling
1 finding
minor“The service needed to improve documentation of actions taken, and whether people were satisfied with the outcome.”