minor“Some staff were unsure of the order they should put on and take off Personal Protective Equipment (PPE).”
minor“Some staff had completed training about infection control but not all. There were no infection control audits in place.”
staff competency
2 findings
minor“One person and one relative told us some staff were not meeting their needs as well as others.”
moderate“Staffs' competency was not assessed prior to administering people's medicines or routinely to ensure they continued to have the correct skills and followed safe practice.”
medication management
1 finding
critical“We saw multiple gaps in recording with no explanation on the Medicines Administration Record (MAR) or daily records to account for medicines or medicated creams not administered.”
governance
1 finding
critical“There were no auditing systems in place to check the service was operating effectively. For example, care plan audits or medicines audits.”
care planning
1 finding
critical“People did not have personalised care plans in place. People's records were not written in a person-centred way and contained insufficient guidance for staff.”
consent capacity
1 finding
critical“Mental capacity assessments for people who were considered to lack the capacity to make decisions about their care and support, were not in place.”
staff training
1 finding
critical“Training records did not demonstrate that all staff had been trained in mandatory subjects such as; fire safety, safeguarding adults, health and safety, first aid, infection control.”
record keeping
1 finding
critical“There was a failure to maintain accurate and fit for purpose care records. These included missing, incomplete or insufficiently detailed care plans and risk assessments.”
missed or late visits
1 finding
moderate“The provider did not record, monitor and review late or missed visits to identify how to reduce these occurring.”
incident learning
1 finding
moderate“The service did not have a systematic recording process for analysing incidents, outcomes and themes, nor lessons learnt for future practice.”
person centred care
1 finding
moderate“One person was living with dementia. There was no care plan and care records only stated, 'I have a diagnosis of dementia so please be patient with me'.”
leadership
1 finding
critical“The registered manager did not demonstrate that they were clear about their role and the arrangements in place to manage the service had not been suitable.”
supervision appraisal
1 finding
moderate“formal staff supervisions to discuss performance and training needs were not being completed for all staff regularly.”
communication with families
1 finding
minor“people told us they were unhappy that they did not always get a rota and were not sure who was coming and what time they were coming.”