critical“the provider had failed to ensure there were safe and consistent systems for the management of medicines which put people at risk of harm”
critical“Steps had not been taken to reduce the potential fire risk for people who used emollient creams. This was despite this risk being highlighted to the provider at our last inspection.”
critical“There were not safe and consistent systems for the management of medicines which put people at risk of harm.”
leadership
3 findings
critical“The provider had failed to have a registered manager in post for the carrying on of the regulated activity of personal care.”
moderate
“the appointed nominated individual was not involved in the management of the service”
critical“There continued to be no registered manager, the nominated individual was absent, and it was unclear who was managing the service in their absence.”
staff competency
2 findings
moderate“staff carrying out these checks continued not to have training at a high level to ensure they had the skills and knowledge to recognise potential errors”
critical“These competency checks had not been undertaken at the last inspection... we only received a competency check for one staff member.”
other
2 findings
critical“The provider had failed to establish and operate effective recruitment procedures.”
critical“Two staff members who had started their induction did not receive their DBS checks until several months after they had begun working.”
governance
2 findings
critical“There were ineffective systems to assess, monitor and improve the quality and safety of the service.”
critical“Quality monitoring systems continued to be insufficient to identify shortfalls and drive continuous improvement in the service.”
safeguarding
2 findings
critical“The provider told us there were no safeguarding concerns. However, the local authority safeguarding team confirmed there was a safeguarding investigation which they had spoken with the provider about.”
critical“we sent a safeguarding referral to the local authority as we were concerned about people's safety. The provider did not contact us until the afternoon of 29th January.”
staff training
2 findings
moderate“although staff had used equipment to help mobilise one person, they had only received on-line moving and handling training”
moderate“it was not possible to concur all staff had been trained as there was not a definitive list of staff who supported people.”
incident learning
2 findings
moderate“there was no evidence that they reviewed people's daily notes and incident reports to ensure staff had taken timely and appropriate action”
critical“The provider told us they were not aware of the incident. This person had also sustained a small cut to their upper lip on 16 January. No accident or incident form had been completed”
record keeping
2 findings
critical“The provider had failed to keep information about the staff they employed at the service.”
critical“Records relating to people's care and support were not accessible... A number of records used by the provider to monitor people's care and treatment had not been completed.”
consent capacity
2 findings
minor“the provider did not have a copy of appointee authorisations... At this inspection, the provider had not obtained a copy.”
moderate“There was no evidence people had been consulted or their mental capacity assessed to evaluate potential risks and so take action to keep people safe.”
supervision appraisal
1 finding
moderate“Spot checks had only been carried out for the senior staff and not the other care staff member to ensure they were providing care to the required standard.”
end of life care
1 finding
minor“there was no evidence that the provider had spoken to people about their wishes at the end of their lives”
staffing levels
1 finding
critical“The provider had no oversight of staff deployment to ensure staffing was kept at safe levels as they did not have access to the staffing rota.”
person centred care
1 finding
critical“People did not consistently receive personalised care that met their needs. This was a continued breach of regulation 9 (Person centred care)”
care planning
1 finding
moderate“there was no guidance for staff as to what may trigger these behaviours or how to best support the person to keep them and staff safe.”
complaints handling
1 finding
minor“The provider was not able to provide any evidence these sessions were taking place.”