critical“'As required' medicines protocol guided staff to administer three different amounts...It was not clear what the prescribed dose was, or when it should be administered.”
critical“Where a medication had been reduced by a medical professional this had not been identified on the MAR chart...We have raised a safeguarding referral about this.”
minor“The medicine record provided guidance about where on the body the cream should be applied but not how frequently. This meant there was risk the cream was not being applied at the times the person needed.”
care planning
3 findings
critical“Care plans continued to fail to contain enough information about people's specific medical conditions...one person's care plan identified they had chronic kidney disease stage three, however, there was no information about this condition.”
critical“One person's care plan said they had a specific medical syndrome. There was no other information relating to this condition. We asked two staff members...they told us, 'I am sorry, I don't know.'”
moderate“risk assessments had not been put in place regarding people's health conditions. These included conditions such cellulitis, chronic kidney disease stage three and diverticular disease.”
governance
3 findings
critical“Quality assurance audits were not in place for example, to check the quality and accuracy of care plans, risk assessments and medicines records.”
moderate“The registered manager told us, 'I have done medication checks, I just haven't documented them.' Any checks undertaken had failed to identify the concerns we found.”
critical“The failure to have effective systems in place to assess, monitor and improve the quality and safety of the service and to maintain accurate and complete records was a continued breach of Regulation 17”
record keeping
2 findings
critical“There were no MAR charts, PRN records, body maps or cream charts for any of these people however, a relative told us, 'Staff administer creams...they fill in a chart.'”
moderate“Records were not always detailed or up to date. This included people's risk assessments, care plans and medicine records.”
staff competency
1 finding
critical“At the last inspection staff had not had their competency to administer medicines assessed. At this inspection staff had still not had their competency to administer medicines assessed.”
infection control
1 finding
moderate“Staff were not testing for COVID-19 in line with Government guidance... detailed guidance about areas relating to COVID-19 such as testing and the use of PPE was not available.”
person centred care
1 finding
minor“the provider had not always acted on people's feedback to make improvements for them.”
leadership
1 finding
critical“The registered person did not demonstrate a robust understanding of how to comply with regulation and sufficient improvement had not been made.”