critical“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service. This was a breach of regulation 17.”
care planning
1 finding
moderate“There was an absence of detail about the care to be provided and people's preferences in relation to their support. Care plans did not provide sufficient detail.”
record keeping
1 finding
moderate“There were no records to evidence how risks had been assessed in relation to people's health to help guide staff.”
supervision appraisal
1 finding
moderate“There was no evidence of an induction, or, for staff or period of work shadowing. This was not embedded or supported through a programme of formal supervision.”
staff training
1 finding
moderate“There was no audit of staff training or recruitment records. Staff confirmed they had an interview before they were recruited. There were no copies of interview notes.”
leadership
1 finding
moderate“The registered manager did not always demonstrate full understanding of the regulations and best practice guidance; for example in respect of person-centred care planning, Mental Capacity Act.”
incident learning
1 finding
minor“Checks were not always signed to evidence the audit or any learning identified. A review of the care plan had not identified the gaps we found in the assessment of risk.”