critical“Where people received 'when required' (PRN) medicines there were no protocols to explain to staff when to administer these medicines.”
critical“several cases where the actual number of remaining tablets did not correspond with what staff had recorded, and instances where the number of remaining tablets had been pre-recorded”
care planning
1 finding
critical“two people who had diabetes did not have plan in place to ensure their condition was safely managed. Risks associated with people's finances, medicines, eating and drinking...were not always thoroughly assessed.”
staffing levels
1 finding
critical
“Four staff members had started their employment without appropriate DBS checks. Their DBS checks were performed several months after their start date.”
governance
1 finding
critical“Management audits and spot checks...did not identify the issues we found with the management of medicines, assessing people's risks and staff recruitment.”
supervision appraisal
1 finding
moderate“there was no formal supervision taking place for the managers and supervisors to ensure they clearly understood their responsibilities.”
record keeping
1 finding
moderate“Four staff members had unreliable references. The service failed to demonstrate the sources of these references...original emails from referees...had been deleted due to administrative issues.”