critical“Medicines were not safely managed. A medicines policy was in place, although this was not being followed.”
critical“Medicines audits were not robust...Audits failed to adequately review medicine administration records and documentation.”
care planning
1 finding
critical“Where staff had to support a person with a catheter, there was no care plan in place to guide staff in how to safely support this person.”
staff training
1 finding
critical“6 staff not having medicines administration training or an assessment of their competency to safely administer medicines, 4 staff not having life support training.”
staff competency
1 finding
moderate“Staff received medication training but did not have their competency checked. Annual competency checks are best practice to ensure staff are safe to administer medicines.”
supervision appraisal
1 finding
moderate“Staff supervision and support was inconsistent and did not meet the needs of all staff. Overall staff said they felt 'unsupported'.”
governance
1 finding
critical“Quality assurance systems were not effective in identifying issues and improving the service.”
leadership
1 finding
moderate“The manager had limited oversight of the day to day running of the service. There was an over reliance on senior staff members to run the service.”
incident learning
1 finding
moderate“Systems to monitor accidents and incidents were not effective and did not promote learning. Audits did not fully consider any emerging trends or themes.”
record keeping
1 finding
moderate“Records of care and support were not accurate or up to date...we were unable to identify if people had received the care and support they required.”
consent capacity
1 finding
minor“Records did not always demonstrate people, or their legal representatives had consented to their care.”