critical“we found shortfalls in training that had been deemed mandatory by the provider. This also included shortfalls in the provision of induction, safeguarding, medicines, and people handling.”
supervision appraisal
1 finding
critical“There were arrangements to provide staff with regular supervisions however this was not always provided in line with the provider's policy.”
governance
1 finding
critical“The provider had failed to maintain good governance. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations, 2014.”
medication management
1 finding
moderate“the training records showed a significant shortfall in the online training which the provider had deemed mandatory for the role including competence checks.”
staff competency
1 finding
moderate“people were not always assured they would receive their medicines as prescribed, by staff who have the right competences to administer them.”
incident learning
1 finding
moderate“we found the system for ensuring lessons were learnt from events was not consistent through the service. Debriefs or incident analysis had not been undertaken in the cases we reviewed.”
other
1 finding
minor“we found in one file employment gaps had not been adequately explored for one staff member.”
leadership
1 finding
moderate“The service was not consistently well-led and leadership arrangements did not ensure effective accountability and oversight.”
record keeping
1 finding
moderate“evidence to show induction completed by staff was missing.”