moderate“one person was prescribed paracetamol for pain relief. We found on several occasions the time gap between doses had been recorded as less than the recommended 4-6 hours.”
minor“handwritten MARs were not always signed by two members of staff to confirm dosage instructions had been transcribed accurately.”
minor“When people were prescribed medicines on an 'as required' basis, protocols were not always in place to inform staff how and when to administer them.”
record keeping
2 findings
critical“Application forms did not provide an assurance that any gaps in employment history had been explored and a satisfactory explanation received.”
moderate
“Regular quality assurance checks of the MARs had not been carried out. This meant the incorrect administration of paracetamol had not been identified.”
staffing levels
1 finding
critical“The recruitment process did not always guarantee thorough pre-employment checks had been completed.”
governance
1 finding
moderate“The provider's governance systems had not identified shortfalls in recruitment processes and medicines documentation.”