critical“Medicines administration records (MARs) were handwritten and did not always provide clear information to staff about how to administer people's medicines.”
critical“Where people were prescribed regular doses of medication, the time of administration was not recorded. This meant we were not assured there was the prescribed gap between doses.”
governance
1 finding
critical“Robust systems were not in place to monitor, review and improve the quality and safety of the service. This placed people at risk of harm. This was a breach of regulation 17(1).”
incident learning
1 finding
moderate
“Accidents and incidents were reported, and action taken to mitigate the risk of events occurring...the registered manager did not have a system to analyse and review themes and trends.”
care planning
1 finding
moderate“One person had fallen and there were no risk assessments in place.”
record keeping
1 finding
minor“Care records could be improved to ensure they contained more individualised information about people's needs and goals.”