critical“Medicines were not always managed safely. Medicine administration records were not maintained in line with best practice guidance.”
moderate“'As and when required' medicines were not clearly recorded in medicine records and did not include instructions about when these medicines should be given.”
governance
2 findings
critical“Quality assurance processes did not take place effectively for care and medicine records. Some care plans were good but others were inconsistent or out of date.”
critical“Medicine audits were not carried out.”
record keeping
1 finding
moderate“There were gaps in people's medicine records which the provider confirmed was staff forgetting to sign.”
care planning
1 finding
minor“some care plans were out of date. As the staff team was very small, staff knew the people they cared for well and their care was not impacted.”
incident learning
1 finding
minor“Lessons learnt were shared with staff via a secure messaging service, however they were not formally recorded.”