critical“Staff did not consistently have Disclosure and Barring Service (DBS) checks completed before they started to work at the service.”
critical“Staff files did not contain evidence of Disclosure and Barring Service (DBS) checks being completed before staff started to work at the service.”
governance
2 findings
critical“Audits completed did not always analyse the information fully. For example, call times were audited but did not detail how many missed or late calls had occurred or if there were any trends.”
critical“Audits which were in place were ineffective at identifying shortfalls and were not meaningful.”
record keeping
2 findings
moderate“Systems and processes had not identified when there was missing information in care plans, risk assessments or tasks requiring staff support.”
moderate“Records about people using the service were not consistent. There were multiple discrepancies between written care plans and what was happening in practice.”
care planning
2 findings
moderate“Not all care files contained the tasks staff were required to support a person with for each call.”
moderate“Some care plans had not been updated to reflect people's current needs...the person was no longer mobile and was cared for in bed.”
staff competency
1 finding
critical“Not all staff had references sought prior to staff commencing their employment. The provider was therefore not assured of staff conduct in their previous employment.”
leadership
1 finding
moderate“The provider had not completed any actions plans to identify when improvements were needed or who was responsible.”
staff training
1 finding
critical“Not all staff were trained in specific care tasks which people they supported had an assessed need for. For example, catheter care, medication administration and moving and handling.”
medication management
1 finding
moderate“When people had 'as required' (PRN) medicines prescribed, records were not always completed to evidence the reason the medicine was administered.”
infection control
1 finding
moderate“Staff were not following government guidance on testing for COVID-19...Staff were only testing if they were symptomatic.”
consent capacity
1 finding
minor“When a person lacked the capacity to make a decision, a best interest meeting was not held.”
person centred care
1 finding
moderate“Some care plans lacked information to guide staff on how to complete care related tasks...one care plan stated 'needs help with personal care tasks'.”