critical“MARs did not include a record of the individual medicines and what each medicine looked like from people's medicine blister packs, therefore staff had limited guidance to identify what medicines they were administering.”
critical“The service was not following the provider's medicine policy in relation to 'as required' medicines... PRN administration records were not in use.”
staff competency
1 finding
moderate“Although staff received training in administering medicines, they did not always receive a medicine competency assessment.”
governance
1 finding
critical
“Auditing systems were not always robust and auditing processes had not picked up on the discrepancies we found during this inspection.”
leadership
1 finding
moderate“In both of the extra care schemes, there was a lack of governance and leadership. The schemes were being led by seniors or co-ordinations with minimal leadership and support.”
consent capacity
1 finding
moderate“There was limited information about people's cognition and mental capacity in their care plans... the provider had no specific mental capacity assessments in place.”
staff training
1 finding
moderate“There was a lack of training completed related to people's specific conditions, such as stroke and asthma.”
care planning
1 finding
moderate“Care plans were limited in detail and did not always include detailed information about people's oral care and their physical or mental conditions.”
end of life care
1 finding
minor“Care plans did not contain people's end of life wishes. The registered manager assured us they will update people's care plans to incorporate their end of life wishes.”
record keeping
1 finding
critical“Systems had not been effectively established to ensure accurate and contemporaneous records were maintained. Regulation 17(2)(c).”