minor“We found some minor improvements were needed in medicine administration records (MAR), including more consistent use of body maps to show where creams should be applied.”
critical“We observed a visiting carer remove the medicines from the blister pack and give them to the person, without first checking the MAR.”
critical“One medicine had been given, but not signed for on the previous twelve days.”
critical“paracetamol had been given at 09.30 and again at 12.30...the safe dosage for paracetamol and tramadol is for it to be given no more frequently than every 4-6 hours.”
governance
2 findings
critical
“The provider had failed to provide consistent oversight of the service. This was a breach of regulation 17 (good governance) of the Health and Social Care Act 2008.”
moderate“Monthly audits of the MARs and care plan documentation were carried out. However, these had not identified the problems we found with medicines management.”
record keeping
2 findings
moderate“Although the majority of care records were comprehensive, some lacked detail. For example, one person who received catheter care did not have an appropriate care plan.”
moderate“Some of the medicines recorded on the sheet did not have a dose recorded against them...signatures to show that a medicine had been given had been omitted on numerous occasions.”
incident learning
1 finding
moderate“There was no over-arching analysis of accident or incidents. We found one person had received minor injuries from a repeated incident, which might have been identified if analysis had taken place.”
supervision appraisal
1 finding
moderate“Staff supervision had fallen behind and had not been carried out every 3 months as outlined in the service staff training policy.”