critical“The provider had failed to ensure there were effective quality monitoring systems and processes in place to monitor quality and safety of the service. Breach of Regulation 17.”
moderate“there were no formalised meetings with minutes as to what had been discussed and the actions agreed.”
moderate“we found some audits had not been completed. This supports the need for the regular and targeted supervision of staff.”
supervision appraisal
2 findings
moderate“Staff supervision and appraisals were not consistently recorded. The staff support plan reviewed showed gaps in the frequency staff had received opportunities to discuss their work.”
moderate
“the frequency of staff supervisions was not consistent. There was no evidence in the files we viewed that staff had had an annual appraisal.”
record keeping
2 findings
moderate“We found one staff member's file to be missing. Another staff file found part of their DBS was missing.”
minor“We found some staff records did not provide evidence that they had received an induction when they commenced work.”
medication management
1 finding
moderate“People's medicines folder did not include details of any allergies or how they liked to take their medicines. Handwritten entries on MAR did not consistently have two staff signatures.”
care planning
1 finding
moderate“One person had specific health care needs, but their support plans and risk assessments had not been updated to reflect changes in their care needs.”
staff training
1 finding
moderate“The provider's staff training plan was not made available during or post inspection...we were unable to confirm staff had received ongoing training.”
safeguarding
1 finding
critical“Some staff told us they did not feel confident in raising a safeguarding incident or concern with the management team. They believed they would not be listened to or action taken.”
leadership
1 finding
moderate“Some staff reported favouritism of staff by some members of the management team. This impacted on staff's confidence to raise issues, concerns or complaints.”
end of life care
1 finding
minor“End of life care wishes had not been discussed or planned for with people and or relatives. The registered manager told us they were aware this needed to be addressed.”
incident learning
1 finding
moderate“the agenda of meetings did not provide an opportunity for staff to learn from incidents and events to make changes to their care practices.”