moderate“one person's risk assessment stated they received medication when they didn't. People's risk assessment needed to be more detailed and person centred.”
critical“One person who had been using the service for two months did not have risk assessments or a care plan in place.”
moderate“further information about how the risk could be eliminated or reduced were not recorded in a risk assessment format.”
record keeping
3 findings
minor“staff recruitment records required improvement to ensure all the relevant information was kept within the staff member's individual file.”
moderate
“We could not establish if the care plans had been reviewed as there were no records.”
moderate“audits of accidents and incidents and spot checks of staff were not recorded in writing to evidence they had been completed.”
staff training
3 findings
minor“a new staff member had completed a range of training, but they had not been enrolled to undertake the Care Certificate.”
moderate“Only two out of seven Watoto staff had completed infection control training.”
critical“Staff were not provided with appropriate training and supervision as is necessary to enable them to carry out the duties they are employed to perform.”
consent capacity
2 findings
minor“We noticed one person had not signed all their consent forms. We shared this information with the director.”
minor“The manager told us they would need to undertake further training to complete [mental capacity] assessments.”
governance
2 findings
critical“The checks completed by the manager and the director to assess and improve the quality of the service provided gave them insufficient oversight.”
critical“most of this was not recorded but carried out in an informal way...there was no written evidence of this. quality assurance systems were not robust”
supervision appraisal
2 findings
moderate“We were unable to determine whether staff were being supported to deliver care and treatment safely...unable to access supervision and appraisal records for staff employed by another company.”
critical“records of supervisions/ meetings with staff had not been recorded. This meant the managers could not evidence they were providing formalised support to staff”
staff competency
2 findings
moderate“There were no records to show the competency of Watoto staff had been checked for the administration of medicines.”
critical“full information regarding each person had not been obtained prior to the person starting work. No written references from previous employers had been obtained”
medication management
1 finding
critical“There was no medication administration record (MAR) for us to check if people had received their medication as prescribed.”
complaints handling
1 finding
moderate“There was a complaints process, but the three people using the service did not have a copy of it in their homes.”
missed or late visits
1 finding
moderate“One person's lunch call was delivered at 3pm on the 1 and 2 July 2018. This person had also experienced four missed calls week commencing 1 June 2018.”
safeguarding
1 finding
moderate“There was no systems in place for staff to record financial transactions to protect people from financial abuse.”
leadership
1 finding
moderate“This decision to outsource the staffing at the service was not meeting the registered providers 'Statement of Purpose'.”