Working at St Clare House

Medication records miss details like timing for pills taken before food, patch sites, and fridge temperatures.

Instructions for medicines which should be given at specific times were not recorded. For example, instructions for six people prescribed a medicine to be taken 30 minutes before breakfast... no system in place to record the site and time of application... Temperature records to ensure the safe storage of medicines were not always in accordance with national guidance.

No paperwork shows checks that locking bedroom doors is in residents best interests when they cannot decide for themselves.

People's doors automatically locked behind them when they left their bedrooms... mental capacity assessments and best interest decisions had not been recorded to make sure this was in each person's best interests and the least restrictive option.

Managers checks fail to spot issues like medication gaps and risks until pointed out by inspectors.

Managers and members of staff qualified to handle medicines regularly completed audits... However, they had not identified the problems we found during our inspection... spoke with the registered manager about developing their approach to auditing to ensure issues would be proactively identified.