moderate“People's care plans were not always clear and detailed... assessments had been completed as prompted by the electronic system when not relevant.”
minor“We identified that some risks had not been assessed and raised this with the registered manager. They took immediate action to review people's care so staff would know how to support them safely.”
staffing levels
1 finding
moderate“Staff were concerned there was not enough staff to cover absence. One said "I worry if I can't cover who will. I try to help where I can."”
governance
1 finding
critical
“Breach of regulation 17 (good governance). Governance and performance management was not always reliable and effective. Some records contained conflicting or unclear information.”
staff competency
1 finding
critical“Some staff had started work prior to receipt of sufficient references. There was no risk assessment for staff with an entry on their DBS.”
record keeping
1 finding
moderate“One person's file said they had PRN medicines but it did not say what it was or where it was kept. Another person's file said they had no PRN medication, but there were two PRN medications on their MAR chart.”
medication management
1 finding
moderate“Not all staff had received up to date training and competency assessments in medicines.”
supervision appraisal
1 finding
minor“The list we saw to monitor these was not robust; it was unclear who was due what and when. The competency assessments included numerous prompts to check, but there was no space for narrative.”
leadership
1 finding
moderate“The registered manager had left in August 2022... the service continued to be managed on a temporary basis and there was no registered manager application yet in progress.”
missed or late visits
1 finding
minor“Another said, "I would like to be informed if they are going to be very late or cancel a visit." Another said, "They just need to sort their timing out then they'll be alright."”
end of life care
1 finding
minor“Not all staff had experience of caring for people at their end of their life. All staff members have been booked to complete training, so they are up to date with their knowledge.”
communication with families
1 finding
minor“A recent survey by phone to people who used the service found that some people didn't know who to complain to. A new updated information pack was produced and provided to people.”