critical“Medicines oversight was not robust. We identified examples where the electronic medicines administration record (MAR) had not been completed.”
critical“Documentation did not demonstrate that medicated patches were applied in line with manufacture's guidance. Staff were not recording the location of the application or removal of the transdermal patch.”
record keeping
2 findings
moderate“Care plans required greater detail where people would sometimes self-administer their own medicines, or when people refused their medicines.”
minor“a risk assessment was missing on the day of the inspection relating to a staff member, in addition to reasons for some staff leaving previous roles was not detailed.”
governance
1 finding
critical“Systems were not robust enough to demonstrate medicines were effectively managed. This placed people at risk of harm. This was a repeated breach of regulation 17 (Good Governance).”
missed or late visits
1 finding
moderate“Not all people were clear on who would be supporting them and when. A person told us, 'The time varies (of the calls), we used to get a rota but we don't now'.”
staff competency
1 finding
moderate“inspection findings identified the need for a greater focus on the recording processes relating to supporting people with their medicines.”