critical“The registered provider had failed to operate effective recruitment procedures to ensure that persons employed meet the conditions as specified in Schedule 3.”
critical“Three staff recruitment files contained references from the same companies with similar handwriting which suggested that both references from different companies may have been written by the same person.”
critical“For three staff recruitment files, the Disclosure and Barring Service (DBS) checks had been completed after the person had started to work for the service.”
governance
2 findings
critical“The registered provider did not have effective systems and processes in place to assess, monitor and improve the quality of the services provided.”
critical
“The lack of management audits and checks meant that the issues we identified during this inspection had not been identified by the registered manager.”
record keeping
1 finding
moderate“Employment records listed on staff members application forms and references provided did not match those as listed on their CV.”
medication management
1 finding
moderate“The medicines management policy did not reference current National Institute for Health and Care Excellence (NICE) guidance on the management of medicines in the community”
staff training
1 finding
moderate“One combined competency assessment had been completed for one staff member and the registered manager. We were unsure why the assessment was combined and how the registered manager had assessed their own competency.”
complaints handling
1 finding
minor“the complaints policy did not provide any information on the timelines within which the provider would deal with complaints received.”
leadership
1 finding
moderate“none of the actions taken, linked to the issues we identified at the last inspection.”