critical“staff did not always recognise when abuse or neglect may have occurred and follow required processes”
governance
1 finding
critical“The provider failed to ensure governance and managerial oversight were effective at monitoring the quality and safety of the service.”
record keeping
1 finding
critical“IT issues across the service meant staff could not always view, review or update care plans and risk assessments.”
incident learning
1 finding
moderate
“Systems to ensure all appropriate actions were taken following safeguarding concerns and medicines errors were still being embedded.”
leadership
1 finding
moderate“Information received is either inaccurate or wrong, it's confusing”
care planning
1 finding
moderate“Issues with the provider's IT systems meant up to date information about risks to people was not always recorded in one place and accessible to all staff.”