critical“MAR charts did not always include medicines that were given on an 'as required' (PRN) basis and were not consistent with the list of medicines in people's care plans.”
critical“Where people were prescribed PRN medicines, there were no guidelines in place to inform staff under what circumstances they should be given.”
moderate“Staff dispensed medicines into multi-compartmental aids (MCAs). This is known as secondary dispensing and does not follow best practice guidance or recommendations.”
care planning
1 finding
critical“One person had a food allergy, but there was no information about the signs or symptoms or what action staff should take if the person had an allergic reaction.”
governance
1 finding
critical“Medicine checks had not identified the issues we found which placed people at risk of receiving unsafe care. Systems were not in place to audit people's risk assessments and care plans.”
record keeping
1 finding
moderate“Record keeping needed to improve. Some recording systems were informal and records of staff competencies in relation to medicines management were not kept.”
supervision appraisal
1 finding
minor“Formal staff meetings were not taking place.”