critical“Medicines administration records (MARs) were poorly maintained and not in line with best practice.”
critical“Staff did not have written guidance in place to follow when medicines were prescribed to be given "when required" or with a choice of dose.”
care planning
1 finding
critical“Pre-admission assessments and care plans were not robust to ensure people's preferences with support and care were captured.”
person centred care
1 finding
critical“Care plans did not record people's preferences regarding personal care or what people liked to eat or drink.”
governance
1 finding
critical“Robust quality assurance systems were not in place to identify shortfalls and take prompt action to ensure people received safe and effective care at all times.”
staff training
1 finding
moderate“staff had not received any training around diabetes care. This meant people were at risk of receiving care from staff who did not fully understand their health conditions.”
record keeping
1 finding
moderate“the stocks of medicines were not recorded accurately. It was not possible to account for these medicines or confirm they had been given as prescribed.”
communication with families
1 finding
moderate“people's ability to communicate was not robustly recorded in their communication care plan, to help ensure their communication needs were met.”
incident learning
1 finding
moderate“Audits were not carried out on aspects of the services, which included medicines, care plans and risk assessments.”