critical“numerous instances where care workers were not accurately recording on the electronic MARs if medicines were being administered”
critical“on one person's MAR for one month, '?' was recorded 22 times in the box. There was no explanation recorded as to what this meant”
moderate“Two people received 'as and when required' medicines (PRN) for pain relief using paracetamol. However, there was no formal PRN guidance”
governance
1 finding
moderate“Medicines audits were not effective as they had failed to identify the shortfalls we found at this inspection.”
incident learning
1 finding
minor“there was a lack of information recorded about subsequent action taken by the provider following an accident/incident and mitigating action to take in future”
record keeping
1 finding
minor“staff meetings...were not documented. The registered manager advised these would be documented in future so that follow up actions could be recorded.”