critical“The plan contained conflicting information about when this medicine should be administered. This put the person at risk which was unsafe.”
governance
1 finding
critical“Systems and process to audit, assess and monitor the quality and safety of the service were not in place.”
record keeping
1 finding
moderate“Information was not available to evidence risk assessments had been reviewed...The ACCESS risk assessment form does not have a review date.”
incident learning
1 finding
moderate
“Staff had not completed an accident/incident report form. This meant information had not been shared or reviewed by the management team.”
medication management
1 finding
moderate“Records were not available to evidence checks had not been carried out to provide assurance people's medicines were administered as prescribed and safely managed.”
communication with families
1 finding
minor“A structured system was not in place to gather feedback from people and relatives about the service provided.”
supervision appraisal
1 finding
minor“Supervisions (individual meetings) haven't always happened due to covering care but we are getting back on track.”