moderate“recruitment records in some cases lacked detail and were not as robust as they could have been. Staff support records lacked structure.”
minor“records were kept in relation to staff support arrangements. These were not structured and did not have an agenda, objectives or clear outcomes.”
moderate“Records such as care plans and risk assessments were not always dated or signed so we could not be assured they were current.”
governance
2 findings
moderate“Quality monitoring audits were in place but would benefit from further development to ensure actions were signed off to improve the effectiveness.”
critical
“The provider did not have effective quality assurance processes in place to monitor the service. This was a breach of Regulation 17 HSCA RA Regulations 2014”
safeguarding
1 finding
critical“Staff had not received safeguarding training and did not fully understand their responsibility to protect people from harm.”
staff training
1 finding
critical“Staff had not had an induction when they started work at the service... staff had only completed three training sessions during their employment.”
staff competency
1 finding
critical“The recruitment process was not robust. pre-employment checks were not consistently completed in accordance with the provider's own recruitment process.”
consent capacity
1 finding
critical“People's mental capacity was not assessed in accordance the Mental Capacity Act (MCA) 2005... two people who lacked capacity had not had their capacity assessed.”
supervision appraisal
1 finding
moderate“Staff received some support and one to one supervision. However... supervision was ad hoc and did not detail a comprehensive record of discussion points.”
care planning
1 finding
minor“Care plans were kept under regular review. However this was not currently being recorded.”