moderate“Gaps in employment histories of recruited staff, or actions taken in regard to chasing second references needed better recording to support the thoroughness of the recruitment process.”
critical“the registered manager had not informed the CQC of a notifiable incident”
moderate“the registered manager told us they were currently auditing one care plan a month. This meant that a care plan may not receive an audit in excess of one year”
record keeping
2 findings
moderate“Employment histories were in place but there were some unexplained gaps on each file viewed. Interview records were not routinely maintained to record if reasons for gaps had been explored.”
moderate
“a person who had recently started using the service did not have clear guidance for staff about their behaviour which could be challenging”
incident learning
2 findings
moderate“they could not recall completing an accident form and there was no completed accident form in the office”
moderate“the 'follow up' section within the accident and incident documentation had not always recorded what, if any, alterations to care and support had occurred”
medication management
1 finding
minor“Staff were doing this for liquid medicines and ointments and needed to extend this to boxed medicines if and when they received them, this is an area for improvement.”
safeguarding
1 finding
moderate“three staff failed to identify the local authority as their primary point of contact to raise safeguarding concerns beyond the service's management”
supervision appraisal
1 finding
minor“senior staff were not having these discussions formalised or documented”
care planning
1 finding
moderate“one person who had recently started to use the service had not had appropriate risk assessments completed”