moderate“these systems did not highlight staff recruitment and incident follow up concerns we identified. When things did go wrong, the provider did not routinely use lessons learnt to improve the service.”
staff competency
1 finding
critical“Evidence of conduct in previous employment, application forms and full employment history were not always in place.”
incident learning
1 finding
moderate“incidents, although fully recorded by staff had not always been followed up or reviewed. This meant we were not assured lessons learned was always effective.”
record keeping
1 finding
moderate“care records did not always record when incidents had been followed up.”
leadership
1 finding
moderate“evidence to show how lessons learnt were routinely used to improve the quality of the service, particularly communications to staff were not in place.”
care planning
1 finding
minor“Systems and processes were mostly in place to assess people's needs prior to care and support commencing. Outcomes for people were identified and regularly reviewed. However, these were often task focussed.”