critical“we did not see any medicines risk assessments or information on where medicines were stored in people's homes.”
critical“Medicines care plans did not always match the medicines support being provided... staff signed to say they had administered the medicines. This was not in accordance with the national guidance.”
record keeping
1 finding
moderate“there was no system to check them for accuracy before using them. We found mistakes and discrepancies on MAR charts that the staff had not identified.”
incident learning
1 finding
moderate
“When medicines issues were identified, staff did not always take action to avoid reoccurrence.”
care planning
1 finding
moderate“Further work was required around risk assessing specific health care conditions, such as diabetes, and formulating guidance to ensure staff were aware of these conditions”
governance
1 finding
moderate“Staff changes and sickness led to delays in the auditing process and, at times, the thoroughness of checks. This, for example, affected the quality of the medicines' audits”
leadership
1 finding
minor“the service did not have a registered manager, which is a legal requirement.”