moderate“No records had been maintained of staff inductions which should include evidence of shadowing opportunities and assessment of staff competency.”
moderate“MAR that was not completed in sufficient detail to understand how much medicine had been administered and when. Where MAR charts had been handwritten and altered...no information to show who had made this alteration.”
moderate“Other than on-line training no records had been maintained of staff inductions which would evidence shadowing opportunities and assessment of competency.”
staff training
2 findings
critical“Staff were not routinely provided with shadow shifts prior to their working with people un-supervised as described in the provider's action plan.”
critical
“Systems were not in place to ensure staff received appropriate induction, support and training that is necessary for their role.”
supervision appraisal
2 findings
critical“I do not know who the manager is. The communication is poor. There are no staff meetings and I've not ever had a supervision.”
moderate“One member of staff told us, 'I have not had any supervision since I started work. As far as I know supervisions only take place if there are concerns with your work.'”
governance
2 findings
critical“The lack of governance and oversight continued to place people at risk of harm. This was a continued breach of Regulation 17.”
critical“The provider failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.”
incident learning
2 findings
moderate“There was no system of management oversight in place to ensure analysis of themes and trends with actions taken to avoid a reoccurrence.”
moderate“Staff required further clarification to ensure escalation processes were clear to all staff.”
care planning
2 findings
minor“We recommend the provider considers further work to ensure care plans in relation to people with a diagnosis of epilepsy describe the type, how this presents and intervention guidance.”
critical“All of the care plans we reviewed contained a lack of information to guide staff in managing the risks in relation to people at risk of choking, falls, prevention and treatment of pressure ulcers.”
medication management
2 findings
moderate“MAR charts had been returned to the office and had been examined by the registered manager, but the above information was not found. The audit in place was not robust enough.”
critical“Medicine administration records (MAR) did not always guide staff as to how these prescribed medicines should be administered.”
leadership
1 finding
critical“The service had been without a registered manager since February 2021. The provider's oversight and governance of the service continued to be ineffective.”
missed or late visits
1 finding
moderate“There have been occasions when staff have not turned up. I call my family who have to come and help me.”
staffing levels
1 finding
moderate“People told us they experienced constant changes of care staff. Staff told us the constant change in management had impacted on morale.”
complaints handling
1 finding
moderate“Not all complaints raised with the provider had been recorded.”
communication with families
1 finding
moderate“Several staff, people who used the service and their relatives told us they were not aware of who the manager was as they had not been kept informed.”
safeguarding
1 finding
critical“We found a potentially serious incident that had not been reported to the office by a carer. This coupled with a previous safeguarding incident that was not reported in a timely way.”
staff competency
1 finding
moderate“Staff competency to administer medicines safely had not always been assessed in line with the provider's medicines management policy.”
end of life care
1 finding
moderate“We were not assured people had been consulted as to their wishes in relation to end of life care.”
person centred care
1 finding
moderate“Care plans did not always reflect how people's choice, wishes and preferences had been assessed. For example, in how they wished their care to be delivered.”
cultural competency
1 finding
minor“Staff were not provided with training in equality and diversity.”