critical“Some of the risk assessments we viewed did not include a management plan to mitigate the assessed risks. For example, where a person was assessed at a medium risk of falls there was no plan in place.”
safeguarding
1 finding
critical“Some staff had limited knowledge of English language and the safeguarding and whistleblowing procedure. The provider's safeguarding policy was only in English.”
incident learning
1 finding
moderate“Records could not be found for these. We also saw that incident and accident monitoring log had not been updated since September 2022.”
medication management
1 finding
critical“2 people were prescribed paracetamol 'as required' medicine but guidance for staff was not available for when to administer this medicine.”
staff training
1 finding
critical“[The training] is very basic. The essential training for staff does not cover mental side of it, it is left out. I don't know if all carers know how to deal with it.”
supervision appraisal
1 finding
moderate“Records showed that some staff did not have a supervision for more than 6 months. Spot checks lacked details as to what specifically was looked at during the observation.”
consent capacity
1 finding
critical“People were assessed based on the principles of the mental capacity assessment when they first started using the service. These assessments were not time or decision specific.”
governance
1 finding
critical“The provider did not have an effective governance systems in place to monitor the care delivery. This resulted the provider failing to pick up and/or act on a number of issues.”
leadership
1 finding
moderate“We could not determine what specific areas of the service the managers were accountable for, including who was responsible for carrying out supervisions and appraisals.”
communication with families
1 finding
minor“Communication should be a lot better; it really is not clear who I should go to if there are changes in [my relative's] condition.”
record keeping
1 finding
moderate“The registered manager told us that some checks were completed by the management team... but that there wasn't a record made which meant it was difficult to track any actions identified.”