critical“gaps in signatures on Medicines Administration Records...time of administration was not always recorded...not assured there was the prescribed gap between doses which put people at risk of harm.”
governance
1 finding
critical“Audits and checks were in place. However, they had failed to identify the shortfalls...relating to the safe management of medication. This was the third consecutive inspection where the provider had failed to be compliant.”
missed or late visits
1 finding
minor“we received mixed feedback about the timings of the calls and people were not always informed if calls were going to be late. One relative said, 'The times of the calls are quite mixed up and varied.'”
incident learning
1 finding
minor“The service had a system for recording and monitoring accidents and incidents. This could be improved to ensure near-miss situations were also captured.”