critical“One person's care plan stated they required staff to support the administration of medicine. However, there was no medicine administration record in place.”
critical“signatures for medicines administered were missing on a number of occasions in January, February and March 2023”
care planning
1 finding
critical“People's care plans did not always contain sufficient information to help staff protect people from identified risks.”
staff training
1 finding
critical“23 out of 85 staff members had not completed the provider's induction training... 38 out of 85 staff were not up to date with their pressure ulcer training.”
governance
1 finding
critical“The registered manager had failed to accurately identify how many staff had completed refresher training... the percentage of staff who were not up to date was actually 70%.”
incident learning
1 finding
moderate“The provider's audits to identify errors and omissions did not evidence staff analysed themes and trends or took sufficient action to prevent staff making repeated errors.”
safeguarding
1 finding
critical“A third person had sustained severe skin damage as a result of staff not having sufficient guidance and training to mitigate the risk of skin damage.”
record keeping
1 finding
moderate“In one person's MAR signatures had been added after medicines were administered on several days for several different medicines for November and December 2022.”