critical“We looked at one person's medicines records and found they did not have a medicines risk assessment, care plan or information about what the medicines were used for and any side effects.”
care planning
1 finding
critical“Another person did not have risk assessments around mobility, falls or personal care. Staff were able to access information on an app, but it was basic.”
consent capacity
1 finding
critical“A staff member had signed off the care plan and there was no evidence the person had been involved in their care planning. The same staff member had signed a second person's consent to care form, without the legal authority to do so.”
governance
1 finding
critical“The provider's systems had not identified the issues seen during the inspection. Audits had not picked this up.”
safeguarding
1 finding
moderate“There was no evidence of how the investigation into the allegation was carried out or what preventative measures were in place to help prevent a similar situation.”
record keeping
1 finding
moderate“The registered manager told us an external nurse completed medicines audits and spot checks were undertaken, however they had no written evidence of these.”
incident learning
1 finding
moderate“It was not clear how lessons learnt were used to help mitigate future risk and improve service delivery.”
staff competency
1 finding
moderate“The provider told us an external nurse completed medicines competency testing, but there was no record of this.”
other
1 finding
moderate“Recruitment procedures were inconsistent. Some staff had appropriate employment references while others did not and gaps in employment were not always accounted for.”