moderate“Staff rosters were not in place to show how staff were allocated to people... instances where staff were scheduled to have attended more than 1 call at the same time”
staff competency
1 finding
critical“Recruitment files did not always contain appropriate references... references for 2 staff members were from organisations which were not listed on their application forms.”
governance
1 finding
critical“Management audits had not been completed effectively... did not reveal shortfalls we found in relation to recruitment, staff deployment and assessing people's risks.”
record keeping
1 finding
moderate“Management records were not always securely stored. The nominated individual told us that a former manager had deleted staff supervision and induction records.”
care planning
1 finding
moderate“Some of the risk assessments lacked detail... for one person who used a hoist to transfer, guidance was brief and did not contain enough instructions on how to safely operate this equipment.”
staff training
1 finding
moderate“Where a person had a specific health condition which required specialised care, such as dysphagia or pressure sores, staff had not received training in these specialist areas.”
supervision appraisal
1 finding
minor“Most staff had not received a supervision due to their short term of employment, but a supervision and appraisal matrix was in place.”