moderate“Information gathered by the service was not effectively analysed and used to drive improvements to the quality and safety of the service.”
moderate“No plan of action was devised in response to this audit. This meant the service had not taken appropriate action without delay.”
incident learning
1 finding
moderate“Accidents and incidents which had been recorded in January 2019, still open on the system and had not recorded the action taken to prevent a re-occurrence.”
record keeping
1 finding
moderate“Clear records were not routinely maintained of all communication made about people and any changes in their care needs.”
staff competency
1 finding
minor“The service did not always explore gaps in employment histories or obtain a reason why the staff had left a previous role.”