moderate“systems to support the provider to have good oversight of the service had not been effectively implemented.”
moderate“the provider was not using the systems effectively to track that actions and learning had taken place”
incident learning
1 finding
moderate“There was a commitment to learning from mistakes, however this was patchy... but other office staff did not recognise this. This demonstrated systems were not fully embedded.”
record keeping
1 finding
minor“some medicine risk assessments had not been updated following an incident and refresher training had not been recorded centrally.”
staffing levels
1 finding
moderate“During staffing shortages, staffing was not always consistent... during this period the quality of rotas and staffing had deteriorated”
leadership
1 finding
moderate“service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”