critical“Topical medicines (creams) were not managed safely. Creams were applied by staff during personal care, but staff did not record when and where these creams were applied.”
critical“People were at risk of not receiving 'when required' medicines safely as there was no guidance available for staff.”
care planning
2 findings
moderate“Personalised support plans were in place, however, they lacked detail about people's support needs.”
moderate“Individualised support plans lacked detail and in some instances were contradictory.”
staff training
2 findings
critical“The provider failed to identify and provide training for staff to support people with specific needs or health conditions. For example; managing diabetes, de-escalation techniques and working with mental health.”
critical“gaps in mandatory training such as medication administration were identified, indicating staff were not adequately trained to meet care needs.”
governance
2 findings
critical“There was a lack of robust and effective quality assurance processes in place to monitor the quality of the service.”
critical“The training matrix was not fit for purpose... did not detail when the training had been completed and therefore, did not identify when training needed to be renewed.”
staff competency
1 finding
critical“The provider was unable to evidence staff had been assessed as competent to administer medicines.”
complaints handling
1 finding
moderate“Complaints were not recorded... people had complained about care staff being late and using their phones during support, but there was no record of this.”
record keeping
1 finding
moderate“There was no system or process in place to record or analyse times of care visits. This presented a potential risk of people not receiving their care at the time required.”
end of life care
1 finding
moderate“Staff were not trained in end of life care and lacked knowledge in this area... there was a risk their needs would not be met appropriately if their needs changed.”
other
1 finding
critical“The provider did not carry out pre-employment disclosure and barring service checks in line with organisational policy and procedure.”
communication with families
1 finding
moderate“The provider had not considered how to ensure the Accessible Information Standard was adhered to. There were no alternative versions of documents to ensure people with specific needs had access to information.”
incident learning
1 finding
moderate“During the inspection, we identified one incident that had not been reported as required.”