critical“All the MAR charts we reviewed had no dates recorded on them and therefore there was no knowledge of which month they referred to.”
critical“A strip of one medicine used to treat high blood pressure had been placed in a box of a different medicine used to treat digestive problems, which meant the person could have been given the wrong medicine at the wrong time.”
critical“Three medicines were identified on their MAR chart but the person described to us that these were all crushed and mixed with water and taken via a syringe. There was no mention or reference to this process anywhere in the MAR's or care notes.”
governance
1 finding
critical“Although medicines were audited and staff were subject to observations of practice and spot checks these interventions had failed to identify the issues we found during the inspection regarding the safe management of medicines.”
record keeping
1 finding
moderate“There was no structure to the way staff were recording information on the rear of MAR charts... handwritten entries for anti-inflammatory medicines and other medicines used for anxiety and tension and none of these were signed or dated.”
incident learning
1 finding
moderate“Records of staff non-compliance to company policies or processes were identified but there was no record of which carer was involved and the actions taken to ensure these errors were not repeated.”