critical“Systems were not used or were ineffective for assessing and monitoring the quality of care, safety and personal needs of people using the service. Breach of regulation 17(1).”
supervision appraisal
1 finding
moderate“We found shortfalls in the staff training provision and staff supervision. This meant the provider could not be assured care workers had the necessary skills.”
staff training
1 finding
moderate“Care workers advised they did not receive effective or regular training. One said, 'The only training we ever got was online training which wasn't suitable as it was talking about care homes.'”
missed or late visits
1 finding
moderate“People, their relatives and care workers told us of staff shortages that had resulted in some people not receiving their scheduled care visits.”
incident learning
1 finding
moderate“The provider did not have a system in place to identify lessons learned and cascade the learning through the staff team to help improve practice and safety.”
leadership
1 finding
moderate“The registered manager left the service in December 2022. Since the registered manager had left some care workers had found the lack of leadership was unsettling.”
consent capacity
1 finding
minor“No training had been provided for care workers to give them an understanding of how to support people when their mental capacity declined.”