moderate“There were no audits undertaken on important quality issues such staff training.”
critical“One member of staff did not have an enhanced Disclosure and Barring Service (DBS) check within their records.”
moderate“Audits to monitor the service and drive improvement were not in place for issues such as the robustness of staff recruitment and people's risk assessments, and whether calls had been timely.”
consent capacity
2 findings
minor“some assessments did require more detail. The registered manager reviewed these assessments during the inspection to show fully how people's capacity had been determined.”
moderate
“Mental capacity assessments had not been completed to determine people's capacity to independently make important decisions.”
care planning
2 findings
moderate“Care plans were not fully personalised as it did not include important information about the person's likes and dislikes and personal history.”
moderate“Checks to people's safety were not always recorded in their care notes. For example, a risk assessment stated a person's catheter needed to be checked on each call. This had not always been recorded.”
record keeping
2 findings
moderate“The care plan did not always contain risk assessments to reduce or eliminate the risk of issues affecting people's safety.”
moderate“People did not have individual personal evacuation plans for the quickest and safest way to leave their homes in the event of fire.”
staff training
2 findings
minor“Staff had not received training in a number of people's specific long-term health conditions such as stroke and end-of-life care.”
moderate“The topics listed did not include safeguarding people from abuse or safe moving and handling practices of people when delivering care and support.”
complaints handling
2 findings
minor“The provider's complaints procedure...did not contain contact details about the complaints authority or details of the local government ombudsman.”
minor“The procedure did not include all relevant information such as how to contact the complaints authority and the local government ombudsman.”
staff competency
2 findings
moderate“This meant the registered manager could not be confident that staff could effectively meet people's needs.”
moderate“The employment history for two staff was not included in their records. The registered manager said this had not been carried out as these staff were agency staff.”
medication management
1 finding
minor“Some additional information was needed to record why and what effect the medicine had. The registered manager amended the protocols during the inspection.”
safeguarding
1 finding
moderate“A staff member was not aware of how to report to other relevant outside agencies if necessary, if they had not been acted on by the management of the service.”
staffing levels
1 finding
critical“Staff recruitment records for the two members of staff were incomplete. They did not include all the pre-employment checks and information required.”
leadership
1 finding
moderate“The registered manager was not able to speak with confidence about the training staff undertook as part of their induction.”