moderate“Quality assurance systems in place had not identified or addressed shortfalls identified during inspection. This included concerns relating to medicines and inconsistency of information”
incident learning
1 finding
moderate“Systems in place to support learning from accidents and incidents contained appropriate information, however they did not always clearly show actions taken to reduce the risk of reoccurrence.”
medication management
1 finding
minor“we did identify one person who received 'as and when' required medicine that was not administered as prescribed. The provider addressed this during inspection.”
record keeping
1 finding
moderate“The provider had systems in place to review accidents and incidents. Records relating to actions taken were not always available.”
communication with families
1 finding
minor“the service sought feedback for concerns raised by staff, however, this feedback was not always shared with staff following the concern being raised.”