critical“Risk assessments did not always contain detailed information about people's risks... actions staff should take to minimise these risks were not always detailed.”
governance
1 finding
critical“The provider did not have effective systems and processes to ensure effective oversight of the service was maintained. Breach of regulation 17.”
incident learning
1 finding
moderate“Accident and incidents had not always been recorded since our last inspection to demonstrate what action had been taken to reduce risks for people.”
medication management
1 finding
moderate“We found gaps in 1 person's records, which had not been explored, and handwritten medication records had not always been signed by the staff member.”
staff training
1 finding
moderate“Some staff had not received training in relation to some of the medical conditions of the people they supported. For example, spinal injury, and stroke.”
record keeping
1 finding
moderate“Late and missed calls were not recorded, and there were no systems to monitor when staff arrived and left their care calls.”
staffing levels
1 finding
moderate“Where staff had commenced employment and shadowing experienced staff before the return of their DBS check, a risk assessment had not been undertaken.”