critical“Staff were late and did not stay for the expected time; it was rare for people to receive a call to advise the care worker would be late.”
staff competency
1 finding
critical“Some staff had been recruited without all the required information. 4 had unexplained gaps in employment history, 1 did not have any photo ID and 1 only had 1 reference.”
infection control
1 finding
critical“The provider's infection prevention and control policy was not dated, there was no information about if or when it would be reviewed, and COVID-19 was not mentioned.”
governance
1 finding
critical“The service's data regarding missed and late visits was not reliable... the service's audits were not robust. They had not identified risk assessments which were either missing or lacked detail.”
missed or late visits
1 finding
moderate“The morning call should be 9am to 9.30am. Carers have come at 12pm. There had been at least 1 missed visit in 7 out of the past 11 months.”
staff training
1 finding
moderate“There was not a tracker for staff competencies, spot checks and supervisions and the training tracker was not completed fully.”
care planning
1 finding
moderate“Risk assessments at the supported living service were very basic and lacked detail. One person's file did not have risk assessments for their oxygen and bed rails.”
medication management
1 finding
moderate“Staff were not all up to date with their medicine administration training... no overall analysis to show how many medication errors had occurred to show themes.”
incident learning
1 finding
moderate“Medication audits of individual clients showed where errors had occurred, and actions identified but there was no overall analysis to show themes among staff or clients involved.”
end of life care
1 finding
minor“People's files did not include care plans specific to their wishes at end of life.”