critical“one person lived with epilepsy but there was no care plan in place to guide staff on what to do should the person experience a seizure.”
governance
1 finding
critical“we were not assured, that these were being fully effective, or reliable, at driving improvements and ensuring that the fundamental standards were being met.”
incident learning
1 finding
moderate“there had been two missed visits. Whilst the root cause of these missed visits had been investigated, an incident form should have been completed.”
supervision appraisal
1 finding
moderate“two staff who were employed in 2020, had no documented supervision in 2021.”
staff training
1 finding
moderate“Three of the four staff had last completed training in moving and handling, medicines management and safeguarding adults in November 2020.”
staff competency
1 finding
moderate“The registered manager was delivering training and undertaking competency assessments in moving and handling, but their qualification to do this had expired.”
medication management
1 finding
minor“People's care plans lacked clarity about roles and responsibilities in relation to the administration of medicines as some of the information recorded was conflicting.”
end of life care
1 finding
minor“this information and the person's priorities for their future care had not been incorporated, by the service, into an end of life or advanced care plan.”
leadership
1 finding
moderate“we were not assured that the registered manager was, in practice, in day to day management of the service, or that they had a sufficient oversight of the provision of care.”
record keeping
1 finding
moderate“Electronic records completed staff at each of the care visits did not provide assurances that two workers had attended each care call, when this was required, or how long the visit had lasted.”