critical“risk assessments or care plans had not been put in place relating to people's health conditions... These included health conditions such Parkinson's disease, epilepsy and contractures.”
missed or late visits
1 finding
critical“They [staff] turned up nearly three hours late by which time [Person's name] had wet the bed.”
staffing levels
1 finding
critical“The failure to safely deploy staff was a continued breach of Regulation 18”
complaints handling
1 finding
critical
“The failure to effectively operate a system for identifying, receiving, recording, handling and responding to complaints was a breach of Regulation 16”
governance
1 finding
critical“The failure to operate effective systems to assess, monitor and improve the service and to maintain an accurate, complete record in respect of each service user was a continued breach of Regulation 17”
record keeping
1 finding
moderate“Risk management records did not always contain enough information for staff to assess, monitor and mitigate risks effectively.”
person centred care
1 finding
moderate“three people told us this had not always been respected. We discussed our concerns with the registered manager who told us of their plans to ensure people were always supported by staff they felt comfortable with.”
staff competency
1 finding
moderate“Staff's knowledge about people's individual health conditions and associated risks was variable.”
incident learning
1 finding
minor“the system needed to be fully embedded as we saw two incidents on daily records that were not in the accident and incident file.”