Working at Widecombe Nursing Home

Managers' audits and checks miss key safety problems like medication errors and hot water risks.

audit and quality assurance of key areas of service provision did not identify concerns we found during the assessment. This meant issues were not always followed up... We found concerns in areas of incidents, medicines processes and the environment.

Medication plans not always followed, plus risks like scalding hot water taps and unlocked sluice rooms.

an agreed covert medication plan for a person was not followed as instructed... water temperatures were checked monthly; however, we identified 3 areas... with access to water at a temperature above 44 degrees... sluice rooms unlocked, putting people at risk.

Staff need refresher training on medicines and incidents due to gaps in understanding and following procedures.

poor understanding and documentation can increase risk to people. The registered manager... carrying out an investigation and providing refresher training for staff... some incidents which had not been reviewed by management.