critical“On one occasion, the provider failed to ensure trained and competent staff were in place to support a person to receive their medicines safely.”
safeguarding
1 finding
critical“In one incident of alleged abuse, a person sustained a significant injury while being supported with moving by staff. There was no evidence of a full investigation.”
record keeping
1 finding
critical“Staff members did not always have a record of their full employment history or previous employment references in place at the time of their commencement of employment.”
staff training
1 finding
critical“4 staff members had not completed training in multiple areas, such as safeguarding. This was despite being employed at the service for over 6 months.”
staff competency
1 finding
critical“No staff members had a recorded moving and handling competency completed and at least 7 staff members had not had a medicines competency check.”
governance
1 finding
critical“Quality assurance systems were not effective in identifying issues and improving the service. Medicine audits were delegated but there was not a consistent approach.”
incident learning
1 finding
moderate“There were 5 incident reports which were reviewed which did not include any actions recorded to reduce future risks.”
care planning
1 finding
moderate“Some people and relatives received a visit from office staff to assess their needs and preferences prior to the start of their care while others did not.”
missed or late visits
1 finding
moderate“The timing is not good at all. I think our 'window' is 9.30-10am, but staff have been as early as 9.15am and as late as 11am.”
person centred care
1 finding
moderate“[My Relative] has dementia yet we have had over 30 different carers and though they connect better with some, they struggle to cope with all the different staff.”
supervision appraisal
1 finding
minor“Staff had completed '1 to 1' supervisions, but these varied in quality. Relevant sections were not always filled out.”
complaints handling
1 finding
moderate“The provider failed to respond to a relative within 21 working days of their concern, which was the timeframe outlined in the provider's complaints policy.”
end of life care
1 finding
moderate“One person did not have an end-of-life care plan. Care plans also did not always include information on actions to take in the event someone deteriorated.”