moderate“We saw in some archived records from October to December 2018 that several medicines had not been signed for...It was not clear if the medicine was not required, was discontinued or had been missed.”
moderate“The providers medicines audits had not identified these issues...We also saw a body map chart for one person, which had detailed two separate topical creams to be applied on the whole body area. This was incorrect.”
governance
1 finding
critical“This was a continued breach of Regulation 17, Good governance. In their action plan dated 03/12/18 the provider stated the breach in Regulation 17, Good governance was 'achieved and ongoing'.”
incident learning
1 finding
critical
“The provider could not tell us what would happen with this information...the provider did not have an audit system in place to monitor and identify trends, when accidents or incidents happened.”
care planning
1 finding
moderate“Care planning audits were in place but they had not been carried out correctly. The audits identified people's needs and not what was required to improve the accuracy of the care plans themselves.”
consent capacity
1 finding
moderate“One capacity assessment had been completed...but this had not been completed correctly or comprehensively...it was not clear from care records if people had capacity or not to consent to receive care.”
record keeping
1 finding
minor“The hoist risk assessment did not contain a service date, when this was due or who was responsible for maintenance.”
staff training
1 finding
moderate“The two senior staff required refresher training in safeguarding and medicines administration. This was last undertaken in 2016 and 2017.”