critical“MAR did not record the name of medicines to be given, the dosage needed or route of administration. People's allergies had also not been recorded on MARs.”
care planning
1 finding
critical“Although the provider had identified risks in relation to pressure areas and continence care, there lacked any guidance for staff on how to support people with their risks.”
safeguarding
1 finding
critical“The provider had not identified possible concerns around neglect... deterioration had not been identified by the provider and so no action could be taken to safeguard the person.”
governance
1 finding
critical“The provider's quality assurance systems were ineffective in identifying areas for improvement... audits were completed, these were not used as a tool to continuously learn and improve care.”
incident learning
1 finding
moderate“The information lacked relevant detail and did not evidence that the provider reviewed incidents to identify any trends or patterns to reduce the risk in future.”
record keeping
1 finding
critical“Medicine records failed to include all of the necessary information to ensure staff supported people with medicines in a safe way.”
person centred care
1 finding
moderate“They don't have a problem with apologising but they don't seem to learn from their mistakes... this was not acted upon.”