critical“People's medicines and medicinal creams had not consistently been accurately transcribed on to Medicines administration record (MAR) charts or signed by staff when they had administered people's medicines.”
care planning
1 finding
moderate“The description of the control and support measures required to help mitigate their risks was basic and did not always provide staff with the information they needed to support people safely.”
record keeping
1 finding
critical“Effective systems to assess and monitor the quality of the service and record keeping had not been fully established. This was a breach of regulation 17.”
staff competency
1 finding
critical“Records of staff training, and competency checks in the administration of intravenous medicines had not been kept.”
governance
1 finding
moderate“The provider did not always operate effective systems to monitor the accuracy and completeness of people's care plans, medicines plans and risk management plans.”
incident learning
1 finding
moderate“Accidents and incidents reported to management team had been investigated and actions taken to prevent reoccurrences. However, people's care plans had not been updated to reflect the actions taken.”
staff training
1 finding
minor“The registered manager was developing improved systems to train and monitor the skills of staff.”
supervision appraisal
1 finding
minor“The provider had identified further development was needed in the development and frequency of staff spot checks, observations, supervisions and competences of staff practices and skills.”