critical“catheter care had not been identified as a risk and therefore lacked an assessment about the risks associated with catheter use and guidance for staff”
critical“provider had completed a risk assessment for pressure sores and identified the person was at high risk, but they had not completed a risk mitigation plan”
critical“the records noted two people were at risk of falls but there were no risk mitigation plans. Another person had asthma but there was no information about how the condition affected them.”
governance
2 findings
critical“quality assurance systems were not being operated effectively as demonstrated by shortfalls identified during the inspection”
critical
“Systems had not been used effectively to assess, monitor and mitigate risks to the health, safety and welfare of people using the service. This placed people at risk of harm.”
incident learning
1 finding
moderate“issues were not identified by the oversight systems, they were not resolved promptly which meant people could be at risk because the quality assurance systems required improvement”
staff competency
1 finding
critical“The provider did not always follow safe recruitment procedures to help ensure new care workers were suitable for the work they were undertaking.”
record keeping
1 finding
critical“The second employee did not have any references. The registered manager said they had received a verbal reference from their last employer, but this was not recorded.”
consent capacity
1 finding
moderate“In one person's record's their relative had signed care plans but there was no evidence the relative had lasting power of attorney (LPA), although the registered manger thought they had.”
person centred care
1 finding
moderate“one person was diabetic and required support with foot care but there was no guidance in the care plan around this.”
end of life care
1 finding
moderate“End of life care was not an integral part of the care planning process. This meant the provider could not demonstrate people using the service were asked about their wishes and preferences regarding end of life”