critical“two Paracetamol had been administered at 18:25, 20:40, 08:30, 11:30 and 16:50, meaning a total of ten had been administered within a 24 hour period”
moderate“MAR's did not contain two signatures to confirm the hand written entry was correct. Best practice guidance recommends that hand written MAR's are checked and signed by two staff members”
moderate“medicines policy contained out of date information or information that the service was not following”
care planning
2 findings
critical“Support plans did not show people had been involved in designing care and support to meet their individual needs and preferences or direct staff on how to meet those needs”
moderate
“identified needs were also pre-populated, such as wash, dress, continence care, shower/bath and staff were to circle relevant ones”
consent capacity
1 finding
critical“support plans that were in place did not contain a signature or evidence that the person had been involved in and consented to the support being given”
governance
1 finding
moderate“Not all the policies and procedures in place contained correct information to guide staff in their roles and responsibilities”
record keeping
1 finding
moderate“no process to document the amount of medicines the person had been discharged with and that staff were responsible for administering”
safeguarding
1 finding
minor“once the initial check had been completed the service did not do any further checks in the future to ascertain if a staff member had received any cautions or convictions”