moderate“further improvement was required to ensure systems were in place to consistently record all safeguarding's and quality information raised by other agencies.”
critical“There was not a robust auditing system in place. This meant the service had not been operating effectively and had failed to identify the concerns we found during the inspection.”
safeguarding
2 findings
moderate“The provider was unclear about their responsibility in notifying required agencies when safeguarding alerts were made or received.”
moderate“Staff training records showed one member of staff had not received safeguarding training therefore we could not be assured they would be able to identify and report concerns.”
record keeping
2 findings
moderate“further improvement was required to ensure a system was in place to make sure information was shared with all other appropriate agencies as required.”
critical“The provider had failed to identify that accurate records relating to people's care were not being maintained, to ensure staff had access to consistent and accurate information.”
incident learning
2 findings
minor“There were no records of any accidents or incidents, therefore we were not able to check records to see what action had been taken in response.”
moderate“There were no records of any accidents or incidents, therefore we were not able to check records to see what action had been taken in response or how the provider was using the information.”
medication management
1 finding
critical“no guidance for people's PRN 'as and when required' medications...no patch charts for medication patches and no record for the count and disposal of controlled drugs.”
care planning
1 finding
critical“No risk assessments or care plans had been completed for three people with specific healthcare needs, which meant staff had no written guidance on how to safely meet their needs.”
staff training
1 finding
critical“two staff had not completed the provider's induction training including training in topics such as infection prevention and control, fire safety awareness and equality and diversity training.”
staff competency
1 finding
critical“staff had not completed moving and handling training with the provider and there was no record the provider had completed competency checks.”
missed or late visits
1 finding
moderate“travel time between calls had not been scheduled and there was no effective system in place to monitor the length of calls times...some calls were significantly shorter than the agreed and commissioned length of time.”
supervision appraisal
1 finding
minor“As it was still a new service care staff had not received supervisions at the time of the inspection.”
communication with families
1 finding
moderate“Two relatives said that there had been a number of different staff to provide care and this was not always communicated. One relative commented, 'We didn't know who [was coming] until they arrived.'”
person centred care
1 finding
moderate“Care plans were not in place for known health conditions, this meant people had not been able to contribute to and agree the care plans for some aspects of their care.”
infection control
1 finding
moderate“We checked training records for three staff and found two staff had not completed training in infection control.”
consent capacity
1 finding
moderate“two out the three care staff had not completed training in people's rights under the MCA and when to act in their best interests.”