critical“we saw documented on body maps people had unexplained bruising and people had missed calls, no further action was taken. This meant people had experienced potential abuse.”
governance
1 finding
critical“There were no quality checks or audits being completed or recorded and subsequently no oversight of the care people received. This placed people at increased risk of harm.”
staff competency
1 finding
critical“One staff member did not have evidence of a Disclosure and Barring Service (DBS) check in their files. The provider was not aware of this.”
medication management
1 finding
critical“Medicines administration records were not consistently completed...dosages were not always recorded. We also saw signatures were missed by staff.”
incident learning
1 finding
critical“There were no incidents and accident forms in place despite daily records identifying concerns. This meant no action had been taken to resolve these incidents.”
complaints handling
1 finding
critical“We saw 3 complaints in a file. These had not been responded to in line with the providers policy...the complaints were not dated, no acknowledgement had been sent.”
staff training
1 finding
moderate“There were no systems in place to monitor staff training or competency. This included in medicines. Staff did not receive supervision to ensure they were proving safe, effective care.”
supervision appraisal
1 finding
moderate“Staff did not receive supervision to ensure they were proving safe, effective care. This placed people at risk of being supported by staff who did not have the training or skills.”
care planning
1 finding
moderate“Most of the care plans and risk assessments we viewed were not dated, it was therefore unclear if these were being reviewed or completed when needed.”
missed or late visits
1 finding
moderate“There were no systems in place to monitor people's calls, including if they were on time, the length of them and if they had taken place.”
record keeping
1 finding
moderate“There were no systems in place that monitored people's calls...When people had missed calls, there were no records of this in the office and no action taken.”
leadership
1 finding
moderate“The nominated individual told us they had been absent from service and on return had identified that improvements were needed, however no action had been taken.”