moderate“A number of consent forms were in place and in different formats. However, they were not always signed by the person using the service or their advocate.”
record keeping
1 finding
minor“people's medicine records did not have photographs to identify the person and personal information was not always written such as allergies.”
incident learning
1 finding
moderate“we found some incidents that should have been reported were overlooked. Lessons learnt were in place, but more work could be done to ensure risks related to incidents could be mitigated.”
governance
1 finding
moderate“We recommended the provider reviews their governance systems to ensure quality assurance was further strengthened.”