moderate“staff were not routinely wearing personal protective equipment (PPE) correctly, such as face masks...staff were unclear as to whether they should be wearing masks”
governance
1 finding
moderate“auditing systems needed further improvements...they did not pick up the shortfalls in respect to the health and safety concerns found at the supported living setting”
incident learning
1 finding
minor“Analyses for themes and patterns to consider if lessons could be learnt were undertaken annually. We discussed the importance of reviewing themes and patterns much sooner.”
other
1 finding
moderate“One person's bedroom contained combustible waste stored behind the fridge, this was a potential fire hazard...communal bathroom flooring contained cracked floor tiles”