critical“Medicines were not always managed safely. The provider did not follow best practice guidance for managing people's medicines. Medicines administration records (MARs) were not kept for each person”
record keeping
1 finding
critical“Care records were not always up to date, accurate or contemporaneous. There was a lack of documentation showing medicines support provided”
governance
1 finding
critical“Systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with the fundamental standards.”
incident learning
1 finding
moderate“Audits of MARs were not always completed. When MARs were reviewed, audits failed to identify errors and omissions.”