critical“The 'cream charts' used were not robust to accurately document administration. The service was not following the provider's medicine policies and PRN protocols were not in place.”
record keeping
1 finding
critical“Improvement was required with record keeping as various records did not contain accurate dates. For example, staff interview records did not specify the dates they were conducted.”
staffing levels
1 finding
critical“DBS checks were not confirmed for the three members of staff until after they started their roles. References were not obtained for two staff members from their previous employers.”
governance
1 finding
critical“The provider had ineffective governance arrangements and failed to maintain accurate complete and contemporaneous records. No audit process was in place for prescribed cream records.”
care planning
1 finding
moderate“Risk assessments were limited and did not look at areas such as moving and handling and nutrition and hydration.”
end of life care
1 finding
minor“People did not have the option to disclose and record their end of life wishes as part of their care planning.”