moderate“Audits were undertaken on a regular basis, however, these failed to identify shortfalls. MAR charts were checked on a monthly basis but failed to identify that the management and recording of medicines was not consistently in line with best practice.”
minor“we saw that there had not been any recent staff meetings...it had been difficult to organise staff meetings recently due to the changes in the management team”
medication management
1 finding
critical“Risk assessments were not in place when medicines were left out, protocols were not in place for the use of 'as required' medicines and MAR charts had not consistently been amended following changes in prescribing instructions.”
consent capacity
1 finding
critical
“Where relatives had signed people's care plans, the provider had failed to determine if they had the appropriate legal authority to do so, such as lasting power of attorney for health and welfare.”
care planning
1 finding
moderate“Specific risk assessments were not in place around how to safely manage the person's care and how to mitigate any risks of infection control when providing catheter or PEG care.”
record keeping
1 finding
moderate“One person's MAR chart identified they were required to use a nebuliser. Their care plan referred to them requiring a nebuliser but failed to explain why and how to safely support the person.”
incident learning
1 finding
minor“Since January 2019, the service had experienced two missed calls. The missed calls had not recorded or reported as incidents.”