critical“We found unexplained gaps on the MAR forms for two people, giving no indication of whether they had received their medicines or not”
critical“staff did not use the correct MAR code 'M=make available' and recorded their initials, indicating they had witnessed the person taking their medicine when they had not”
staff training
1 finding
critical“Staff spoken with confirmed they had not received 'practical' moving and handling training but were supporting people to mobilise.”
staff competency
1 finding
moderate“Staff had received medication training but had not had their competency assessed through direct observation to ensure their practice was safe.”
supervision appraisal
1 finding
moderate“since commencing in post in February 2021 and May 2021, two members of staff had only received one supervision, 11 and eight months respectively after being employed”
governance
1 finding
critical“The quality assurance and governance arrangements in place were not effective in identifying shortfalls in the service.”
record keeping
1 finding
moderate“A full employment history was not recorded for two out of four staff personnel files viewed.”