critical“people were put at risk of harm because systems were not robust and records about care were not complete and contemporaneous. This was a breach of regulation 17.”
critical“the provider had not operated effective systems to ensure safe recruitment and had failed to ensure that all staff understood child protection reporting procedures”
incident learning
2 findings
critical“we were alerted to serious incident which had not yet been reported to CQC...we were not able to fully assess how learning from incidents had occurred.”
minor“The provider's process was clear about identifying reasons for incidents but was not written in a way which ensured lesson were learned when things had gone wrong.”
record keeping
2 findings
moderate“Recruitment records were not always accurate and up to date...Daily logs required more details about people's choices. Some logs did not detail duration of visits.”
minor“the provider's statement of purpose was not updated to reflect this”
safeguarding
2 findings
critical“The registered manager was not aware this was a reportable incident...This was submitted in retrospect.”
critical“the provider had not followed the correct reporting process in line with child protection procedures as these were not understood by the registered manager”
consent capacity
2 findings
minor“consent forms contained some details, but were not signed by people using the service or where appropriate their legal representative.”
minor“Where children were approaching adulthood, the provider was yet to carry out preparatory work to ensure that their future care was delivered in line with the MCA.”
staff competency
2 findings
critical“employment dates were missing on all of the employment and character references we checked to ensure staff had provided accurate information”
minor“Some parents told us that sometimes care workers did not speak good English. The provider had arranged for staff to undertake English courses when this was identified as a development need.”
care planning
1 finding
moderate“questions related to the assistance a person required and frequency, these were left blank. Also, risks related to the use of a bath board were not documented.”
staff training
1 finding
moderate“I have worked for Ashton Care since [month] and I haven't received any training at all. Neither have [other staff].”
supervision appraisal
1 finding
moderate“Staff records showed staff had completed training...This conflicted with staff feedback, none of the staff we spoke with had received training or a formal supervision.”