critical“Quality assurance systems were not robust enough to demonstrate there was an accurate and complete record of the care and treatment people received.”
critical“The provider did not have a governance system in place to assure themselves of the quality and safety of the service.”
critical“There was not an effective system in place to asses, monitor and improve the quality and safety of the service and to identify where improvements were needed.”
critical“the provider of Knighton Road did not have an effective governance system in place to assure themselves of the quality and safety of the service. This was a breach of Regulation17”
care planning
2 findings
critical
“Where people had complex healthcare needs, the provider had not developed an accompanying care plan to guide staff how to safely support people with this aspect of their care.”
moderate“A quality assurance audit had identified improvements were needed to ensure people's plans of care were person centred and were developed with the involvement of the person.”
record keeping
2 findings
moderate“Where daily records were completed, they included little to no information about the care provided, with only basic tasks being checked off.”
moderate“Training records were not easily accessible and therefore it was difficult to ascertain when staff had undertaken training and if their training required updating.”
person centred care
2 findings
moderate“Care records were not always person centred and did not always reflect people's preferences.”
minor“People did not always have knowledge of their plans of care and other information written about them and was kept within their home.”
medication management
1 finding
critical“The provider did not have risk assessments for people prescribed anticoagulant medicines...no guidance for staff to follow if a person at risk of excessive bleeding was injured.”
consent capacity
1 finding
minor“Documentation around how a person's capacity was assessed was not always clear.”
staff competency
1 finding
moderate“This was a tick box approach and did not record what practices had been observed, how staff's competence was being assessed, whether the member of staff was competent.”
supervision appraisal
1 finding
moderate“Staff were provided with regular supervision and appraisal however the information was not analysed and used to develop the service or used to produce action plans.”
communication with families
1 finding
minor“Two people commented that they found staff who spoke in their first language to each other when providing their care was of concern as they were excluded from the conversation.”