critical“Quality assurance systems were either not in place or did not operate effectively. Audits and planned monitoring were not in place and therefore had not identified the shortfalls found within the inspection.”
medication management
1 finding
moderate“Medicines assessments and instructions were not always detailed and in place for staff to follow. Guidance had not been created to ensure medicines taken 'as required' were offered consistently.”
care planning
1 finding
moderate“Instructions on safe ways of working to reduce or eliminate risks were not always documented. The information did not always inform care planning and was not always personalised.”
incident learning
1 finding
minor“Learning from incidents was not always shared within the service and providers locations.”
record keeping
1 finding
moderate“Completed medicine administration records (MAR) were not visible to staff who were responsible for daily oversight of care visits.”