moderate“action plan was conducted in August 2022 for the service which identified gaps and missing information, but these had not been resolved.”
medication management
1 finding
moderate“There was a missing PRN protocol in a persons medication folder and the medication audit did not identify this.”
incident learning
1 finding
moderate“action plan also identified that a trend review was needed for all accidents and incidents in July 2022 and in August 2022 but this had not been completed.”
end of life care
1 finding
minor“There was limited information in the support plans we reviewed relating to people's end of life wishes.”
complaints handling
1 finding
minor“The service did not have a formal complaints audit. The area manager told us they would complete this on a monthly basis to analyse any trends or themes.”