critical“People did not have 'as needed' medicine protocols in place in line with best practice guidance.”
moderate“Medicine administration records (MARs) we reviewed had gaps in administration, but it was not clear why.”
staff training
2 findings
moderate“Staff had not completed training in the MCA and did not always have a full understanding of the MCA.”
moderate“seven staff members had not completed up to date training in topical medicines”
governance
2 findings
critical
“The provider failed to ensure that effective governance systems were in place. This is a breach of regulation 17(1) (Good Governance)”
critical“Medicines audits had not been completed since May 2022. This meant that staff errors could have been missed.”
supervision appraisal
1 finding
moderate“Most staff had not received a one to one supervision to review their practice and professional development since the new management team was put in place in January 2022.”
consent capacity
1 finding
moderate“Three further care plans we reviewed did not include signed consent from people or legal representatives.”
leadership
1 finding
moderate“There had been no registered manager in post at the service since October 2021.”
record keeping
1 finding
moderate“records of staff signing to confirm they had read people's care plans were not complete”
incident learning
1 finding
moderate“we also saw an incident report of a person who had a fall but there were no recorded actions to reduce further risk of falls.”
infection control
1 finding
minor“One relative told us some staff do not wear PPE.”