critical“Prescribed medicines recorded on MAR charts were inconsistent. Some directions for oral medicines were incomplete and some coding systems were not consistently in place.”
critical“We found gaps on some MAR charts. Staff had not completed the records to evidence whether the medicine had been administered.”
critical“When people had their medicines given to them via a tube through their skin (PEG), records did not show that the service had taken appropriate professional advice.”
staff competency
1 finding
moderate“Some members of care staff had not had their competence assessed annually in line with national best practice guidance.”
record keeping
1 finding
moderate“Care plans did not always cross reference people's needs. Information was not cross referenced for a person who required equipment and another who required rescue medicine.”
governance
1 finding
moderate“The medicine audits had not identified the concerns we found during the inspection. The provider agreed to ensure improvements were made after inspection.”
care planning
1 finding
moderate“One person's records did not evidence that staff were consistently following the strategies regarding repositioning.”