critical“The manager did not have knowledge of how to refer a person at risk to out of hours services. They were unaware of the local and county-wide procedures.”
critical“There was a reference in a person's record to a safeguarding allegation. There was no documented fact finding, investigation report or referral to the local authority.”
governance
1 finding
critical“The provider had not established an effective system to enable them to ensure compliance with their legal obligations and the regulations. Breach of Regulation 17.”
leadership
1 finding
critical
“There was no registered manager in post at the time of the inspection. The provider had not complied with their conditions of registration.”
care planning
1 finding
moderate“When we examined the person's support plan, it had not been updated since 25 December 2021.”
supervision appraisal
1 finding
moderate“Supervisions were previously completed for former staff, but the current care worker did not have regular supervisions documented. There were no performance appraisals completed.”
record keeping
1 finding
moderate“The provider was unable to access the systems for a significant period. They did not update care and other records during this period. No retrospective entries were made.”
incident learning
1 finding
moderate“There was no evidence that lessons were learned from the incidents, that information was shared with the staff team, and that measures were in place to prevent recurrence.”
person centred care
1 finding
moderate“Likes, dislikes and preferences were not adequately detailed in the support plan. The person's needs and choices had not been updated in the support plan.”
consent capacity
1 finding
minor“The manager was uncertain about how to check a person's lasting power of attorney, enduring power of attorney or Court of Protection orders.”
infection control
1 finding
minor“The manager had not reported mandatory data online about infection prevention and control. We had prompted the manager on more than one occasion to use the national tracking system.”