critical“Individual care and support plans had not been provided for everyone. Those that were provided were limited in content and did not describe clearly the person's care, their preferences or reflect any changing need.”
governance
1 finding
critical“There were no established and effective processes in place to monitor and improve the quality of the service, ensure compliance with the regulations, or to reduce risk to people.”
record keeping
1 finding
critical“Some records were absent or incomplete. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
staff training
1 finding
critical“The provider had failed to ensure staff had the appropriate training, skills to support people safely and in line with best practice and the law.”
staff competency
1 finding
moderate“There was no evidence that they had completed any induction training or that their skills and experience had been assessed before starting work for the agency.”
end of life care
1 finding
critical“Most people were receiving end of life care and support. There was no care plan to support staff to respond to specialist support needed or any emerging need.”
leadership
1 finding
moderate“The service had lacked effective leadership. There were policies and procedure available...However, these had not been adapted or adopted into practice.”
supervision appraisal
1 finding
moderate“Systems to capture feedback from staff had not been established. Supervision and team meetings were not used to capture staff views.”
safeguarding
1 finding
critical“Risks associated to people's safety had not been considered...people who were at risk of falling or needed moving with equipment did not have suitable risk assessments.”