moderate“There were gaps in all audits reviewed. They needed to be widened in scope and further embedded to support continual improvement of the service.”
moderate“Quality improvement systems including audits in all areas needed to be further improved and embedded to ensure a system of continual improvement and learning took place.”
leadership
2 findings
moderate“Leaders oversight of the service needed to be more robust to support the governance of the service.”
moderate“Leaders needed to be more familiar with their policies to guide the delivery of the service to ensure governance procedures were effective.”
supervision appraisal
1 finding
moderate“Supervision, checks of practice and observations needed to take place more regularly.”
staff training
1 finding
minor“Some mandatory training needed to be completed, actions were in place to address this.”
other
1 finding
minor“Staff were recruited safely, however recruitment records needed further improvement... We recommend more robust procedures for overseeing recruitment are embedded.”
medication management
1 finding
minor“Some medicine administration records needed further information which was addressed during the inspection following feedback.”