critical“People's care plans identified risks to their health and wellbeing but did not always contain information about the risk, or guidance for staff on how to mitigate the risk.”
moderate“risk assessments did not always contain guidance for staff to manage the risks.”
governance
2 findings
critical“The provider had not established effective governance systems to ensure the service was operating in line with policies and procedures.”
critical“systems to monitor quality were not always effective and did not always demonstrate how action was taken to address issues raised. Systems to monitor the quality of the service did not identify our concerns.”
staff training
2 findings
moderate“The provider did not have an effective system in place to ensure staff received training in line with the training policy.”
critical“not everyone who visited this person had received the correct training. This placed the person at risk if they had a seizure.”
missed or late visits
2 findings
moderate“People and their relatives told us that whilst things had improved since the last inspection, staff were still not always punctual.”
minor“Sometimes they [staff] come very early and on a few occasions in the evening it's been very late, they did call to let me know and so I cancelled the call.”
supervision appraisal
2 findings
moderate“supervision/spot check meetings for staff had not been held regularly since the last inspection, but we saw a supervision schedule was now in place.”
moderate“supervisions were not held regularly and there had not been a staff meeting held this year.”
record keeping
2 findings
critical“The systems to monitor quality were not always effective and records were not always accurate or up to date.”
moderate“three people's care plans contained inconsistent information regarding support they required with their medicines and two peoples care plans contained incorrect information about their mobility.”
staff competency
1 finding
critical“two people had received care calls by staff that had not been trained to provide the specialised care required. This meant people had been placed at risk of harm.”
medication management
1 finding
moderate“Records relating to the administration of medicine were not always accurate or up to date. We found three people's medicine assessments and support they required was not always clear.”
incident learning
1 finding
moderate“We could not always see where learning was used to improve the service... more robust documentation was required.”
infection control
1 finding
moderate“the policy and information shared wasn't always up to date... a system to monitor the frequency and results of staff's bi-weekly COVID-19 tests had not been implemented.”