critical“Staff currently administering medicines had not had their competency assessed in line with best practice guidance. This was a breach of regulation 12 (Safe Care and Treatment).”
critical“Not all records showed that people received their medicines as prescribed. The records for a person who received their medicines topically did not evidence administration in accordance with the prescriber's instructions.”
care planning
1 finding
moderate“When people required support with medicines, they did not always have a care plan in place. This meant people were placed at risk of harm as information was not available to guide staff.”
governance
1 finding
moderate
“Auditing systems were in place. However, we found that they were not always effective...not all concerns found with risk assessments, electronic call monitoring and medicines management had been picked up.”
supervision appraisal
1 finding
minor“There were processes in place to complete supervisions and spot checks however, these had not always taken place in line with the providers schedule.”
leadership
1 finding
moderate“The registered manager delegated audits. However, they did not always have full oversight of the outcomes to ensure all relevant legal requirements were understood and met.”
consent capacity
1 finding
minor“We identified a lack of understanding regarding MCA processes and when there was a need to complete a mental capacity assessment.”