critical“DBS checks completed up to 5 months after the staff member's start date. The registered manager told us care staff would not have undertaken care tasks alone during this time, however they were unable to evidence this.”
governance
1 finding
critical“The providers governance systems were not always robust and effective at identifying improvements needed. This was a breach of Regulation 17 (Good Governance).”
care planning
1 finding
moderate“People's care records did not always include clear guidelines for staff in how to manage risks to their care. This placed people at risk of harm.”
missed or late visits
1 finding
moderate“a person had a care call for 16 minutes when the planned call was 30 minutes. Another person received a 15-minute care call when it was planned for 30 minutes.”
staff training
1 finding
moderate“Not all care staff had up to date training such as in healthcare tasks.”
communication with families
1 finding
minor“several people shared examples of challenges with communication, where English was not the care staff's first language, and not knowing which member of care staff to expect for their visit.”
record keeping
1 finding
critical“There were inconsistencies with obtaining staff references and the suitability of these. The system to ensure all necessary checks on staff were completed before being employed was not robust.”