critical“Medicines were not always managed safely. Medicines administration was not always recorded on Medicines Administration Records (MARs).”
governance
1 finding
critical“Management did not complete checks and audits in relation to the completion of MARs. The last time a MAR audit was completed was 5 January 2023.”
record keeping
1 finding
moderate“They failed to record all complaints, outcomes and lessons learnt on a centralised system.”
care planning
1 finding
moderate
“One person had epilepsy, but there was no personalised risk assessment detailing signs to look out for and what action to take in the event of a seizure.”
staff competency
1 finding
moderate“Staff were trained in the safe administration of medicines...However, staffs' medicines competency was not checked to assess their ongoing level of skill.”
supervision appraisal
1 finding
minor“Supervision notes...were generic and lacked detail about what was discussed during these sessions. It was also not evident that supervision sessions were tailored to individual staff.”
staff training
1 finding
minor“We found that some staff required refresher training and raised this with the registered manager who acknowledged this and said that staff were in the process of completing this.”
complaints handling
1 finding
moderate“There was no centralised system for recording complaints and their outcomes...no record of lessons learnt following a complaint.”