moderate“Some quality audit systems were not always effective at identifying issues...the medicines audit did not identify there were no systems to record transdermal patch application.”
minor“The service did not have a formal business continuity plan in place to detail how the service should be run safely in the event of exceptional circumstances.”
medication management
1 finding
critical“Systems were not in place to ensure the safe administration of transdermal patches...no system for staff to record where they had administered a transdermal patch”
care planning
1 finding
moderate
“Some health associated risks for people were not assessed to guide staff on how to respond to these risks. For example, breathing difficulties or blood thinning medicines.”
record keeping
1 finding
moderate“Risk assessments to support safe recruitment decisions were not always effective. The risk assessments used by the provider did not identify how the risk would be minimised.”