moderate“Quality assurance systems did not always operate effectively. Audits were not always present, complete or robust.”
minor“The service had not actively sought formal feedback on the quality of the service... not always recording the views of people to drive improvements.”
incident learning
1 finding
minor“There was no formal review of accidents as a service and we raised this with the provider.”
supervision appraisal
1 finding
minor“Formal supervisions had not been recorded within the guidance of the providers policy, this had been identified and was being addressed.”
consent capacity
1 finding
minor“MCA assessments had been completed. However, assessments were not always considering individual decisions.”
end of life care
1 finding
minor“The service did not always routinely plan for end of life needs.”