critical“We identified a fridge used to store medicines was not operating consistently within the recommended temperature range to help maintain the effectiveness of the medicine.”
critical“A best interest decision was not recorded about this decision... A covert medicine policy was not in place and a pharmacist had not been consulted to ensure the way the medicines were administered was safe.”
moderate“instructions on how one medicine should be taken conflicted with the guidance on the protocol. This meant the medicine may not be effective if given.”
governance
2 findings
critical“Systems in place to assess, monitor and improve the quality of the service were not robust and did not drive the required improvements.”
moderate
“We found the audits of the service did not cover all aspects of care delivered and meant risks may not be identified and acted upon.”
incident learning
1 finding
moderate“Analysis of accidents and incidents was not completed to identify patterns or trends throughout the service however actions were taken for individuals to prevent a re-occurrence.”
consent capacity
1 finding
moderate“One person was given some of their medicines covertly. A best interest decision was not recorded about this decision”
record keeping
1 finding
minor“audits were not accurately dated and only stated 'September 2021' this meant it was not possible to be precise about when the checks had been completed”