moderate“During the pandemic the provider had reduced oversight of systems and practices that protected people from the risk of abuse.”
moderate“The monthly audits had not all been completed by the team leaders. This meant that the information held by the registered manager was not up to date.”
moderate“domiciliary staff did not have team meetings and no spot checks had occurred to assess the quality of support being delivered by staff.”
incident learning
2 findings
moderate“The provider identified some improvements were required to ensure systems to prevent the risk of abuse were effective.”
minor
“We saw good recording of incidents but no analysis of the information.”
medication management
2 findings
moderate“we noted five missed signatures on a MAR form. This was for medicines prescribed to be administered by gel. This made it difficult to assess whether people had received what was prescribed.”
minor“There was no annual competency observation in place for the team leaders.”
staffing levels
2 findings
moderate“people being supported in the domiciliary service did not always get their allocated hours at the agreed times.”
moderate“priority was given to the supported living service at the expense of those who used the domiciliary service.”
safeguarding
1 finding
critical“Concerns had been raised that not all staff had always delivered person centred support... concerns received about some people being at risk of abuse.”
record keeping
1 finding
minor“gaps in employment had not been explored and documented at interview.”