critical“The registered manager had not ensured staff were being regularly tested for COVID-19 in line with current government guidance.”
moderate“the registered manager did not have robust systems in place to monitor infection control practices as we did not see any monitoring of staff practices to ensure that staff were using PPE correctly.”
governance
1 finding
critical“The registered manager did not have effective quality assurance systems to monitor service delivery as they had not identified the issues and concerns, we found at the inspection”
care planning
1 finding
moderate
“The provider did not have care plans in place for the person they provided support to. They did have a copy of the person's care plan from their primary care provider which they relied upon.”
staff training
1 finding
moderate“The registered manager had not provided training to the staff team as they had sought evidence of training certificates from previous employers”
staff competency
1 finding
moderate“We were unable to determine from the documentation if staff had been assessed as competent to administer medicines as the registered manager did not have these records.”
supervision appraisal
1 finding
moderate“Staff were not clear on who was responsible for delivering supervision which meant the registered manager was not following their policy”
missed or late visits
1 finding
moderate“The registered manager was not monitoring call times due to the size of the service. This meant that we were not assured the person was receiving their care at the agreed time each morning.”
other
1 finding
moderate“Staff were not always recruited safely as two people did not have full employment histories. The registered manager was also not aware that this was a legal requirement.”
person centred care
1 finding
moderate“The provider had not ensured care was delivered in a person -centred way as daily records were task focused.”
communication with families
1 finding
moderate“The registered manager was not aware of the AIS standard and within the assessment process we did not see any sections where people's communication needs could be recorded.”
cultural competency
1 finding
moderate“People's diverse needs such as culture, religion and language spoken were not considered as part of the assessment process.”
record keeping
1 finding
moderate“We reviewed the person's file and we read about health issues which were no longer relevant. This told us the provider was not reviewing their paperwork in line with their policy.”
safeguarding
1 finding
minor“We reviewed the providers safeguarding policy and we found some of the information was out of date.”