critical“Recording on medicine administration records (MAR) had not always been completed appropriately... codes used for when a medicine was not given were not always correct and we found multiple missed signatures.”
critical“Prescribed thickener... had not been consistently signed as administered or documented... This put people at risk of not receiving their medicines as prescribed.”
governance
2 findings
critical“The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided. This was a breach of regulation 17”
critical“Audits completed on medicines were not effective. The audits completed had not identified the issues we found with missing signatures and recording of medicines.”
record keeping
1 finding
critical“Not all mitigating strategies for known risks were recorded... staff had not consistently recorded how much thickener was used, the water temperature before supporting a person with bathing or urine output”
care planning
1 finding
moderate“Some care plans held incorrect information... one person's care plan stated they required thickener in fluids but refused to have thickener. However, this was incorrect”
consent capacity
1 finding
moderate“records did not always document the questions asked or answers received to detail the decisions made regarding the person's capacity.”
supervision appraisal
1 finding
minor“Not all staff felt they received regular supervisions.”
communication with families
1 finding
minor“some relatives felt communication could be improved between staff and relatives.”
incident learning
1 finding
moderate“after one significant event the duty of candour had not been completed.”