minor“The monitoring of training and supervisions was not always accurate. The monitoring system displayed incorrect dates and some training which had been completed was not recorded.”
critical“Suitable references had not always been retained in staff files. Risk assessments around information held on a DBS check were not in place at the time of our inspection.”
medication management
1 finding
critical“Staff did not always record the reason why they hadn't administered someone's medicines... this information was not recorded robustly on the medicine administration records.”
governance
1 finding
critical
“The provider failed to have systems and processes in place to effectively monitor and improve the quality of the service. The provider was not able to provide us with any evidence of audits.”
incident learning
1 finding
moderate“The provider did not have clear systems and processes in place to identify when things went wrong, and then effectively learn lessons.”
leadership
1 finding
moderate“At the time of our inspection there was not a registered manager in post. A new manager had been recruited during the inspection process.”
communication with families
1 finding
minor“One person told us 'communication could be improved' and that on occasion they 'had difficulty getting through to the office.'”