critical“a person required a patch...every three days. Records showed the patch had been given every four days. This error had not been identified by the staff administering the medicine.”
critical“the guidance for the amount of paracetamol a person should have in one day was not recorded...given this medicine five times a day on several occasions.”
moderate“Protocols for the administration of 'as needed' medicines were not always in place...could result in inconsistent medicine administration.”
care planning
2 findings
moderate“risk assessments that had been completed over a year ago with no evidence of a review date and other risk assessments that did not have the date of completion recorded.”
moderate
“one person had a catheter bag and the care plan stated how staff should empty the bag. However, there was no corresponding risk assessment on how to minimise the risks of cross infection.”
governance
1 finding
critical“the audits for the assessment of the risks related to medicines and ensuring care plans and risk assessments were always reflective of people's current needs were not effective.”
leadership
1 finding
moderate“Some people referred to a previous registered manager, others referred to the deputy manager. Few were aware who the current registered manager was.”
complaints handling
1 finding
minor“they rarely received feedback or a follow-up to their concern. One person told us that whilst their complaint had been listened to, they did not have confidence that it would be acted on.”
incident learning
1 finding
minor“it was not always clear what actions had been taken to reduce the risk of recurrence or whether the actions taken had been effective.”