critical“People's medicines were not always managed safely. Policies and procedures did not follow current national guidance and staff had not been properly trained.”
safeguarding
1 finding
critical“The policy stated that the registered manager would undertake investigations...and only refer incidents 'of a more serious nature' to the local safeguarding authority.”
staff training
1 finding
critical“Three staff had not undertaken any training; one had been with the organisation since it opened in 2013...and had no previous experience of care work.”
staff competency
1 finding
critical“Staff had not received suitable induction to ensure they could safely work unsupervised...two staff were working towards the qualification but they did not know how much progress the staff had made.”
supervision appraisal
1 finding
moderate“One member of staff had been employed since January 2016 and there were no records of supervision or spot checks. Two other staff...had received only two supervisions.”
care planning
1 finding
critical“One person had a care plan for three visits a day but their needs had changed and they received a live in care package and another person had a pressure sore but there was no risk assessment.”
governance
1 finding
critical“The registered manager confirmed that they had not undertaken any audits or assessments of the service...was not aware of any of the shortfalls highlighted during this inspection.”
record keeping
1 finding
moderate“A number of these records were not dated, timed or signed. In addition, some records were incomplete or illegible.”
leadership
1 finding
critical“The registered manager admitted that she knew what the regulations required but allowed staff to work without proper checks or basic training.”
consent capacity
1 finding
moderate“Only one member of staff had completed training in the MCA. One consent form had been signed by a next of kin...although there was no evidence...of a Lasting Power of Attorney.”
incident learning
1 finding
moderate“Another person had fallen twice whilst being assisted by staff to shower. No risk assessment had been carried out and the person told us that they still worried about falling.”
missed or late visits
1 finding
minor“A common issue was that staff arrived late to their calls...'They can sometimes come too early or too late. I have seen it when they come to help my mum for tea at 6.30pm and then come back at 7.30pm'.”