moderate“other accidents and incidents had not always been followed up or responded to robustly. We found the records regarding the action taken were not always detailed or clear.”
minor“lessons learnt were not always effectively shared with staff. Following the inspection, the manager addressed this through staff meetings.”
care planning
1 finding
moderate“not all risks had robust risk assessments in place. For example, risk assessments for the fire risks from paraffin based topical medicines were not in place.”
medication management
1 finding
moderate
“not all PRN ('as required') medicines had PRN protocols in place. Following the inspection, PRN protocols were implemented.”
record keeping
1 finding
moderate“5 out of the 6 staff files reviewed had gaps in the staff members employment histories.”
governance
1 finding
moderate“Quality assurance systems, processes and audits were completed regularly however, they did not consistently identify some of the concerns found on inspection.”
leadership
1 finding
moderate“they had left the service in May 2020 and had not deregistered from the service… there had been other managers who had not stayed.”