Working at Maylands

Medications weren't handled safely, with missing signatures on records, pain patches not tracked properly, and night shift stock mismatches.

Medicines were not always managed safely. Two people had pain relief patches... staff did not record the position... handwritten entries had not been double signed... stock did not match the documented numbers.

Managers didn't spot issues because audits on care plans, medications, and incidents weren't thorough enough.

There was no robust audit system to review care plans... Medicine audit systems had been ineffective... no oversight of accidents and incidents, to review for trends and patterns.

Risk guides for problems like choking or constipation lacked detail or weren't kept up to date.

Risks to people had been assessed but guidance in place was not always up to date or with enough detail. For example, when people were at risk of choking, there was no guidance for staff to follow.