moderate“the provider had not ensured all staff had completed mandatory training in line with their own policy or checked staff's competency”
moderate“Not all staff had been provided with specialist training relating to working with people with a learning disability or autism, or communication skills.”
care planning
2 findings
moderate“Staff did not have one clear support plan to follow, the staff followed various care plans written by different specialist professionals which had not been reviewed regularly and sometimes provided contradictions.”
moderate“Care plans required updating to ensure they reflected staff practice; staff were not trained to use any restraints on people but one care plan referred to 'holds.'”
supervision appraisal
1 finding
moderate“Staff had not received supervision as outlined in the provider's policy”
person centred care
1 finding
moderate“they did not include person-centred planning tools and approaches to support people to reach their outcomes. Staff were not always aware of people's goals”
governance
1 finding
moderate“there was no audit systems in place. The registered manager told us they reviewed daily records for quality assurance but had no records of this.”
missed or late visits
1 finding
moderate“The provider had a record of missed and late care calls but had not considered reviewing this to look for themes and trends to improve the service”
record keeping
1 finding
moderate“documentation relating to recruitment was not always robust”
incident learning
1 finding
moderate“Recorded incidents were not always appropriately investigated for learning opportunities to improve the service.”
end of life care
1 finding
minor“Care plans outlining people's preferences for end of life care were not in place... Staff had not received any training in end of life care”
staff competency
1 finding
moderate“When staff had been recruited from previous health and social care backgrounds, we could not be assured suitable checks had taken place to ensure they had the suitable skills.”