Working at Coton House

Some staff training is overdue, like refreshers for epilepsy awareness, moving and handling, and deprivation of liberty.

records showed staff had training in epilepsy awareness, moving and handling and deprivation of liberty safeguards was overdue for a refresher course.

Medication records had mismatches between stock and records, missing signatures without follow-up, and no guidance for as-needed medicines.

We checked medicines records and stock and found these did not match. ... missing signatures on medicines administration record (MAR) sheets with no explanation and no escalation. Where people had ‘as required’ medicines, guidance was not always in place.

Oversight systems missed problems in risk assessments, care plans, and medicines audits.

The oversight system in place to ensure peoples risk assessments and care plans were accurate had not identified where these were incorrect. The medicines audits had not identified the lack of PRN protocols, when actions were not taken to address missing signatures or when stock records were inaccurate.