moderate“we saw two medicine errors where staff had reported it to the provider but had not consulted an appropriate health professional in line with the provider's policy”
safeguarding
1 finding
moderate“we identified one incident where the service had not followed procedures to notify the local authority of a potential safeguarding concern”
governance
1 finding
moderate“systems for auditing daily records and medicine records were not robust... audits did not follow a clear framework and staff did not record what they had looked at, findings or actions arising from their audit”
record keeping
1 finding
minor“people's medicine and daily records were archived sporadically, which meant in some cases people's records had not been checked for several months”