critical“The provider had failed to ensure governance systems were established and operating effectively to ensure risks were managed and learning shared”
incident learning
1 finding
moderate“there was no process for analysis and review to enable the service to identify trends, learn lessons from events or prevent reoccurrence”
infection control
1 finding
moderate“not all staff had received training in infection control, half of the staff team had not received training and only eight staff out of 68 had received training”
staff training
1 finding
moderate“36 staff out of 68 had not completed mandatory epilepsy training and a further 14 staff needed a refresher”
leadership
1 finding
moderate“Oversight from a provider level had not identified the shortfalls within the service. The provider told us they did not have a formal audit and measurable system”
communication with families
1 finding
minor“The service had not actively sought formal feedback for the service since 2019.”
record keeping
1 finding
minor“the passports were not always up to date with the correct contact details”