critical“a series of errors when community support workers were assisting people with their medicines...staff not understanding or following the policies and procedures in place”
moderate“ten medication errors being identified over a twelve month period...introduction of half hour visits in place of 15 minute visits”
incident learning
1 finding
moderate“there had previously been a lack of analysis of accidents and incidents, and consequently a lack of evidence of any learning”
safeguarding
1 finding
moderate“the services threshold for submitting safeguarding alerts was previously too high...not all medicines errors were referred to the safeguarding adult's team”
governance
1 finding
moderate“The provider had recognised that previous quality audits had not been robust. This, along with the number of medicines errors, led to a full review of the service.”
record keeping
1 finding
minor“There was no system to record occasions when staff failed to turn up at someone's home”
staff training
1 finding
minor“staff who had not completed the required training were already booked on a training course, with the exception of food hygiene”