critical“Staff did not always follow best practice guidance...no body maps to guide staff on the administration of these medicines and no medicines administration records (MAR) to confirm administration.”
moderate“Not all staff had completed a medicines competency assessment to ensure training was embedded and that they had the necessary skills to administer medicines.”
governance
2 findings
critical“There were no recorded medicines audits to ensure people received their medicines as prescribed. We found a possible gap in a medicines record which had not been identified.”
moderate“Daily support notes staff made as a record of care were not checked for any issues or concerns. Spot checks were completed but these were not recorded.”
record keeping
1 finding
moderate“Some MAR's were handwritten by staff due to communication problems with a pharmacy. However, there was no check made that the handwritten MAR corresponded accurately with the prescription.”
leadership
1 finding
moderate“There were some gaps in the manager's awareness of their responsibilities and role. For example, in relation to their awareness of the duty of candour regulation.”
complaints handling
1 finding
minor“The complaints policy did not explain all the options where to take a complaint externally if someone was not happy with the outcome of a complaint.”
care planning
1 finding
moderate“Risk assessments had not been recently reviewed. The manager showed us their improvement plan which had identified this issue and a full review of risk assessments was underway.”