minor“Further written developments were needed in regard to people whose emotional health and subsequent behaviour might require different ways of support.”
moderate“Care plans did not always give staff clear guidance on how to deliver care or support… where people had some form of dementia there was no information to guide staff”
incident learning
1 finding
moderate“There had been a recent occasion where a safeguarding concern had been identified...but had not understood the need to notify the commission.”
missed or late visits
1 finding
minor
“We saw past staff rotas had not allowed sufficient time for travel between visits. However we saw rotas were now changed to give sufficient time for staff to travel.”
governance
1 finding
critical“There were not adequate systems to monitor and improve the quality of the services provided. This was a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) 2014”
record keeping
1 finding
moderate“There was no system to maintain an audit trail of all key staff recruitment documents which ensured that people had been recruited robustly and were fit to work in the care sector.”
staff training
1 finding
moderate“There was no system to record and monitor staff training which meant some staff training was out of date or had not taken place.”
supervision appraisal
1 finding
moderate“There was no formal supervision in place for live in carers who, although self-employed, were managed by the agency as were the care packages they were employed for.”
safeguarding
1 finding
critical“We saw there was no risk assessment or plan to mitigate any risk in place which is required when a person's DBS had disclosures.”
staff competency
1 finding
moderate“A number of staff had not received the [DBS] clearance until a couple of months after they began working.”
person centred care
1 finding
minor“Another care plan read that the person was able to prepare and cook their own food which was not the case as food was prepared for them.”
communication with families
1 finding
minor“One relative said they felt they needed to check when there was a change in medicines as care staff did not always hand over information about medicines.”