moderate“We saw no evidence of regular management meetings with a set agenda, minutes and actions recorded. We were told that conversations occurred across the senior management team, but these were not formalised nor documented.”
moderate“the provider had a risk register but did not identify all expected risks and whilst dates of entry and mitigations were in place, we saw no dates for review nor staff allocated to manage each risk.”
incident learning
1 finding
moderate“staff not having adequate breaks between shifts. This had been highlighted in three successive monthly audits and we saw no evidence of any actions taken to understand how this was happening.”
medication management
1 finding
moderate
“We requested the service policy for ensuring the safe storage and transfer of patient's own medicines during transfer but were told that the service did not have one.”
communication with families
1 finding
minor“The service did not provide information leaflets available in languages spoken by the patients and local community.”
leadership
1 finding
minor“We saw limited communication from managers to the wider staff team, we saw no regular staff meetings and no formalised way of keeping staff informed.”