minor“Some records would benefit from more detail around the levels of support that people needed with medicines and their abilities to administer their own medicines safely.”
critical“five medicine administration records (MARs) we checked contained multiple gaps on different days... not possible to be sure whether people had received their medicines”
record keeping
1 finding
moderate“handwritten entries on the five MARs we viewed had not been signed or dated.”
governance
1 finding
critical“no auditing checks of MARs for January and February 2019, which meant the provider had not identified the significance of the MAR's containing missed signatures.”
staff competency
1 finding
critical“references had been received 8 months after the member of staff commenced employment. For one member of staff no references had been obtained.”
care planning
1 finding
moderate“two care plans were not personalised in setting out what was important to the person, how to support them, their life history, and their likes, dislikes and preferences.”