critical“Audits had failed to identify medication administration records, and medication administration, were not being carried out in line with the provider's policy.”
moderate“Audits did not record what action was to be taken, by whom and when and subsequent audits showed improvements were not consistently achieved.”
moderate“The systems that were in place had not identified that mental capacity assessments were not decision specific and that best interest meetings had not been held.”
medication management
2 findings
critical“People's medicine administration records did not always record the dosage or the name of the medicine prescribed.”
critical
“A person's care records instructed staff to administer medicine from a dosset box prepared by a family member and not by a pharmacist.”
consent capacity
2 findings
moderate“The best interest decision was not supported by a clear and agreed protocol of care for staff to follow.”
moderate“not all MCA's were decision specific. The provider met with people and their families [where appropriate] and updated the MCA's and best interest assessments before the inspection was concluded.”
staff competency
1 finding
moderate“We could not be confident in the competency assessments of staff given they were not consistently following the provider's policy or procedure for medicines.”
safeguarding
1 finding
minor“Not all staff were aware of external organisations they could refer safeguarding concerns to. For example, the local authority safeguarding team.”
record keeping
1 finding
moderate“The topic such as 'notes audit' and 'medication records' was followed by a tick or yes, with no information as to what evidence had been used to assess quality.”
supervision appraisal
1 finding
minor“Staff had not yet had an appraisal of their performance but plans were in place to complete these.”