critical“Not all risks for people had been fully assessed and plans put in place to mitigate those risks as far as possible.”
medication management
1 finding
critical“Staff had not been assessed as competent to administer medicines safely. Procedures were not in place or followed to ensure medicines were always been managed safely.”
staff competency
1 finding
moderate“no assessments of staffs understanding of the online training and how this should be put into practice such as medicines or moving and handling competencies had been undertaken”
supervision appraisal
1 finding
moderate“there were no supervision records for the other four staff whose files were viewed... The provider was therefore not following their own procedures”
consent capacity
1 finding
critical“Suitable procedures were not in place to ensure people's rights under the MCA were recognised and ensured.”
governance
1 finding
critical“The provider's quality assurance processes were not effective and had failed to identify concerns we found and improve the quality and safety of the services provided.”
record keeping
1 finding
critical“MARs charts for specific people whose care plans we had reviewed we were told these were not available as they had not been returned to the office”
complaints handling
1 finding
moderate“the failure to formally record these meant patterns or trends may be missed and action not taken to reduce the likelihood of similar concerns”
communication with families
1 finding
moderate“They [Lone Care Services] put two people with him that can`t speak or understand English so I can`t go out!”
leadership
1 finding
moderate“Most people or their family members were unsure who the registered manager was. Several named an office staff member who they thought was the manager.”
other
1 finding
critical“The registered person has failed to ensure that all necessary pre employment checks were completed.”