critical“When people were prescribed 'as required' (PRN) medicines, protocols were not in place to document when, why and the dosage of medicines should be given.”
critical“1 person's MAR did not have the dosage of a medicine recorded...there were 7 days when another medicine had not been signed to evidence it had been administered.”
governance
2 findings
critical“Systems and processes were not in place to audit medicine records to identify any issues or concerns.”
critical“The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
care planning
1 finding
critical“Not all risks to people had been assessed. We found 2 people had missing risk assessments and mitigating strategies for known risks.”
record keeping
1 finding
moderate“We found no evidence of systems and processes being in place to audit records or check all information was up to date, factual and relevant.”
person centred care
1 finding
minor“Care plans required more person centred information within them to support new staff to understand and get to know people and their needs.”