moderate“there was no evidence to demonstrate staff had had their competency assessed to ensure they were skilled to undertake this task safely.”
record keeping
1 finding
moderate“there was no evidence of a second reference having been received for three out of four members of staff.”
safeguarding
1 finding
moderate“The DBS certificate for one member of staff was received 17 days after they commenced in post. There was no evidence of a completed Adult First Check or risk assessment.”
staffing levels
1 finding
critical“rotas identified staff working for 96 hour or more shifts... staff were not able to have a full period of sleep and were working unsafely and excessive hours with no breaks.”
governance
1 finding
moderate“monitoring visits... failed to identify that staff allocated to 24 hour packages of care were working excessive hours with no breaks.”
leadership
1 finding
moderate“A registered manager was not in post at the time of inspection... formalised quality audit systems were not yet fully established and embedded within the service.”
person centred care
1 finding
minor“Another person who had a 24 hour care provision in place was also requesting a later time for going to bed and the service was unable to meet this request.”