critical“On two occasions staff who had tested positive for COVID-19 had continued to work and isolated with people in their own homes”
moderate“A large number of staff had not received Infection Prevention and Control training for over four years, and there were no competencies in place to ensure good practice in this area.”
governance
2 findings
critical“Governance processes were not always effective to hold staff to account, keep people safe and provide good quality care and support.”
critical“Governance systems to ensure the safety and quality of the service were not robust. The telephone audit system introduced at the start of COVID-19 was still in place despite government guidance changes allowing visits.”
record keeping
2 findings
moderate“There was no effective system to check care records were up to date...care records included inaccurate and duplicate information and there were some gaps in monitoring records.”
minor“Some care records contained unclear information. For one person who had a specialist health condition there was conflicting information about when the GP should be contacted.”
medication management
2 findings
minor“One person had received an 'as required' medicine on a regular basis and staff had not asked the doctor for a review.”
moderate“Where people needed their medicines 'as and when required' protocols required more guidance for staff to follow. The lack of guidance increased the risk of people not having their medicines when required.”
staff training
2 findings
minor“Staff told us they had attended more specialised training...this information was not recorded on the provider's training matrix.”
critical“The provider shared their training matrix which showed a significant number of staff had not received some training for over four years. This included mental capacity, infection control, fluid and nutrition, health and safety.”
care planning
1 finding
moderate“Some care plans had more than one set of guidance for staff and the guidance was different with no date so it wasn't clear which one should be followed.”
communication with families
1 finding
minor“Some relatives were not aware of the complaint's procedure or the management structure of the service.”
safeguarding
1 finding
critical“Where a whistle blowing concern had been raised about potential neglect, the provider had failed to follow procedures to safeguard vulnerable adults and there had been delay in reporting the concern to the relevant external agency.”
consent capacity
1 finding
critical“Decisions had been made on behalf of people who lacked capacity without the principles of the MCA having been followed. This included using surveillance equipment and administering medicines covertly.”
staff competency
1 finding
critical“Regular competency assessments were not taking place to ensure staff had the skills and knowledge to support people. Some staff hadn't had a medication competency completed for over four years.”
incident learning
1 finding
moderate“The provider had not taken enough action to share learning across the organisation and improve care following a safeguarding incident.”
person centred care
1 finding
moderate“The service had not explored how to support people in the least restrictive way. One person was unable to access their kitchen due to identified risk. Alternatives had not been explored.”