critical“Some of the systems to assess, monitor and improve the quality of the service were not fully effective. This was a breach of regulation 17 (Good Governance)”
staffing levels
1 finding
moderate“There were not always enough staff on duty to meet people's needs. Staff vacancies and absence had led to low staffing levels on some occasions.”
medication management
1 finding
moderate“Medicines audits were not sufficient in fully identifying the circumstances behind identified errors.”
other
1 finding
moderate“Staff were not always recruited safely, we found gaps in completed application forms and some applications forms did not match staffs curriculum vitae (CV).”
incident learning
1 finding
moderate“Accidents and incidents were recorded. However, the management team were working to implement a new reporting system to gather more details and information, so lessons can be learnt”
complaints handling
1 finding
minor“the service had recorded cancelled calls and declined calls but had not recorded reasons for them. Some people had cancelled multiple calls in a month and there was no recording of alternative support offered”