Working at Gainsborough Care Home

Medication handling has gaps like missing double checks, incomplete records, and unsafe storage that risk overdose or missed doses.

MARs were not routinely double signed by staff meaning the second check for accuracy was not being completed. We saw a person who had been prescribed Co-codamol had also received paracetamol... This is a risk as both contain paracetamol... TMARs had not been fully completed.

No dedicated activities coordinator so the role is mostly routine personal care with basic ad hoc events like music or crafts.

There were no activities staff currently employed, and activities were provided either by care staff or through external entertainers... not having an activities staff member meant activities were ad hoc.

Some risk assessments are incomplete or missing, like no plan for people with very thin skin that could break down easily.

A person who had ‘tissue thin skin that was intact’ had no tissue viability care plan or risk assessment in place... the risk of developing wounds... had neither been assessed nor mitigate.