critical“on four occasions in November 2017, as required (PRN) medicines prescribed to treat pain, were not administered to a person requiring them due to an absence of suitably trained staff”
critical“a member of staff had made five errors between October 2016 and November 2017, and had continued to administer medications with no additional training or competency assessments”
critical“Thickening agents were not stored securely...kept in an unlocked kitchen cupboard...people could access the thickening agent”
moderate“the temperature in the medication room frequently exceeded the maximum temperature for safe medicines storage”
infection control
1 finding
minor
“During the inspection we found an action plan from a legionella risk assessment had not been fully completed.”
record keeping
1 finding
moderate“daily records did not always include these details...one person's daily record contained the entry, 'Lower body care cream applied'. This person was prescribed three different topical medicines.”
incident learning
1 finding
moderate“information was not effectively collated to allow effective identification of trends. This could mean that causes of accidents would not be known and addressed to prevent further occurrences.”
governance
1 finding
moderate“medicines audits contained a 'check competencies' section, which was always recorded as being 'complete'. However, staff who had made medicine errors had not always had their competencies reassessed.”
consent capacity
1 finding
minor“Staff did not always complete written capacity assessments or document best interest decisions.”