critical“We found widespread lack in record keeping that should be in place to make sure people's care was appropriate.”
minor“Spot checks were carried out on an on-going basis although these were not documented. Staff meetings were held as required, but mainly on an individual basis.”
minor“We noted one person had no photo ID and only one reference documented in their staff file.”
governance
2 findings
critical“there was no evidence that audits for any part of the service had taken place, including actions to ensure staff were safely recruited.”
minor
“There was no current documented audit process in place but the provider was aware of the need to implement this if the service grew.”
care planning
1 finding
critical“The care plan we reviewed was basic and there was no evidence this had been reviewed or updated. Staff told us they did not have access to written care plans or risk assessments.”
staff training
1 finding
moderate“not all staff had received safeguarding training in line with best practice guidance and some were unclear on their safeguarding responsibilities.”
safeguarding
1 finding
moderate“not all staff had received safeguarding training in line with best practice guidance and some were unclear on their safeguarding responsibilities.”
leadership
1 finding
critical“The provider did not have an effective management structure. The provider did not monitor the quality of care provided in order to drive improvements.”
staffing levels
1 finding
critical“Recruitment processes were not robust to ensure staff were suitable to work. This was a breach of regulation 19 of the Health and Social Care Act 2008.”
incident learning
1 finding
moderate“The provider had not consistently created a learning culture at the service which meant people's care did not always improve. However, there were no recording systems to support this.”
supervision appraisal
1 finding
minor“Although there was not a formal plan of supervision and appraisal, the registered manager and staff told us this was a continuous process.”