moderate“training for staff in support of people who needed help to manage their diabetes safely was not fully up to date”
moderate“Established staff had not always been provided with the refresher training that the registered person had planned...including training in how to provide basic first aid and how to achieve good standards of food hygiene.”
minor“quality checks completed by the registered person had still not resulted in all staff receiving all of the training they were considered to need.”
missed or late visits
2 findings
critical“Out of a total of 33 visits there were 16 occasions when staff were either early or late...four occasions when the visit missed its correct start time by more than one hour.”
moderate
“19 of the visits had been completed at the right time with the remaining visit having been late by a small amount of time.”
governance
2 findings
critical“Shortfalls in completing quality checks and in receiving feedback about the service had increased the risk that people would not reliably receive care that met their needs.”
moderate“further improvements still needed to be made in the way some quality checks were completed... had not always effectively and quickly resolved problems.”
complaints handling
1 finding
minor“when we looked at the information we saw it did not include the contact details for the health service ombudsman”
staffing levels
1 finding
critical“Shortages of staff had resulted in an increased number of visits being included in each round and that this had resulted in a greater likelihood of visit times becoming unreliable.”
medication management
1 finding
critical“Two occasions when staff had not completed a visit at all...people had been placed at risk of harm because they had not been supported to take their medicines at the correct time.”
supervision appraisal
1 finding
moderate“Staff had not met with someone senior as frequently as the registered person said was necessary in order to review their work.”
record keeping
1 finding
moderate“Quality checks had not been recorded and so we could not be confident about whether they had been comprehensive.”
leadership
1 finding
minor“The registered person had not engaged with initiatives such as the 'Social Care Commitment' and 'Dementia Champions'...reducing opportunities staff had to reflect upon and develop their professional practice.”
other
1 finding
moderate“Background checks had not always been completed before new staff had been employed...including obtaining references from previous employers.”