Working at St Anne's Community Services - Heatherstones

Medication is not handled safely, with missed doses, wrong records, and no checks on thickeners.

Medicines were not managed safely. Medicine administration records demonstrated that people did not always receive medicines as prescribed. We found that people had missed doses of some medicines, stock did not match records... Staff did not record when thickener powder was added to drinks.

Management oversight is poor, audits miss repeated problems like medication errors.

Monthly medicine audits took place; however, these were not comprehensive and had not found the issues we found during this inspection. There had not been enough learning from a previous medicines error as it had re-occurred. The provider's quality systems were not robust enough... This was a breach of Regulation 17.

Only standard training with gaps, no proof all staff are checked yearly on giving medication.

We did not see annual competency training records for all staff who administered medicines, so we could not be sure this was always done properly.