critical“there were no records for staff to confirm that they had applied this medication, and there was also a lack of information about where on each person it should be applied.”
critical“we noted an incident where a person was accidentally given a double dose of medicines by staff. We raised this with the registered manager, who had not been made aware of this incident.”
record keeping
1 finding
moderate“Often there was no staff signature to show who had completed this form and at times the form lacked detail. For example, we saw some medicines were recorded to be administered "as directed."”
governance
1 finding
moderate
“we identified shortfalls within the management of medicines that this increased auditing had failed to identify, indicating that the audit lacked completeness.”
incident learning
1 finding
moderate“When medication issues were reported there was no matter of urgency or anyone contacting us back to see how the patient was or any feedback as to what was happening.”
person centred care
1 finding
minor“A number of people told us that the provider used to give them a printed rota...but they said that this practice had recently ceased, which they were unhappy about.”