moderate“records did not include the dose amount that had been given and administration charts were not in line with the prescription.”
moderate“administration records did not include all required information for staff to follow on how and when this medicine may be required.”
governance
2 findings
moderate“Medicines audits did not identify our findings in relation to PRN protocols, consistency in electronic records for variable dose medicines or application information.”
moderate“audits of people's care records failed to identify our findings where there were inconsistencies in completion of the provider's assessment tools.”
consent capacity
1 finding
critical“a relative had provided consent on the persons behalf without the appropriate legal authorisation to do so.”
care planning
1 finding
moderate“where a person had recently been prescribed a modified diet, their care plan had not been appropriately updated to robustly detail their current needs.”
staff training
1 finding
moderate“some staff had not completed up to date training in medicines administration and moving and handling practical sessions to ensure they were competent in their role.”
infection control
1 finding
minor“policies and risk assessment information specifically in relation to COVID-19 did not reflect current best practice guidance.”
communication with families
1 finding
minor“people and their relatives were not always aware which staff would be attending the call. 'No we don't ever know who is coming and when, it's all very ad hoc'”
record keeping
1 finding
minor“one person's recruitment file did not demonstrate their full employment history and...satisfactory evidence of their conduct in those roles had not been sought.”