minor“the registered manager made regular telephone calls to people to monitor staff timekeeping, however they did not record the outcome of these monitoring calls.”
moderate“Care plans did not contain information on the model or maintenance history of moving and handling equipment being used to ensure it was safe to use.”
governance
2 findings
minor“minutes of the meetings were repetitive and did not indicate these were an open forum which allowed staff to share ideas and raise issues or concerns.”
critical“The provider did not have effective systems in place to monitor the safety and quality of the service as there were no formal audits or quality assurance checks.”
medication management
1 finding
critical“one person's daily logs showed staff had administered their medicines on several occasions... 'Yes, I only give them when the family member is too busy.'”
care planning
1 finding
critical“The risk of skin breakdown had not been recorded in the care plan and there were no instructions in place to ensure staff knew how to mitigate the risks.”
consent capacity
1 finding
critical“Mental capacity assessments were not carried out when the provider had cause to suspect people did not have capacity to consent to their care.”
staff competency
1 finding
moderate“Staff received training in the administration of medicines, however, their competency had not been assessed in line with best practice guidance.”
infection control
1 finding
critical“Staff were not carrying out twice weekly COVID-19 tests according to current government guidelines.”
other
1 finding
critical“References obtained prior to employment did not provide satisfactory evidence of conduct in, or reason for leaving, previous roles working with children or vulnerable adults.”
person centred care
1 finding
moderate“One person's care plan stated they 'can become vicious' during personal care. There was no information in the care plan about what staff could do to alleviate the person's anxiety and distress”
communication with families
1 finding
moderate“People's communication needs were not assessed, and care plans contained insufficient information about people's communication preferences.”
end of life care
1 finding
moderate“People had not been consulted about whether they had any end of life preferences.”
cultural competency
1 finding
moderate“Care plans did not contain any information about people's cultural or religious needs or protected characteristics.”
leadership
1 finding
critical“The registered manager had been unwell and unable to attend work for several weeks; however, they had not made suitable arrangements for the management of the service in their absence.”