moderate“one person's care plan informed staff that they needed their medicines administering and advised to leave one medicine in a pot to take later. This had led to occasions where the person did not take their medicine.”
record keeping
1 finding
moderate“staff were signing the medication administration record (MAR) that the medicine had been administered and handing over in daily care notes that they had been left out for the person to take later.”
governance
1 finding
moderate“Senior staff audited medicine records to check medicines were given in line with the prescriber's instructions, however there was no record of an audit for these occasions identified.”
end of life care
1 finding
minor“Guidance was not available in people's care plans about their end of life wishes, although there were currently no people receiving end of life care at the time of our visit.”