moderate“recommended higher level specialist training had yet to begin. One staff member told us, 'I think we need better training knowing how to respond when the clients are upset'”
minor“new staff did not receive a face to face induction meeting and felt this would be helpful. The manager said this would be reviewed.”
care planning
1 finding
critical“one support plan addressed a different person's PEG management. This did not record how staff would monitor the PEG, the frequency or amount of water to use to flush or how to manage blockage”
record keeping
1 finding
critical
“daily notes by care staff had been retrospectively entered into people's care record. This included when medicines had been administered.”
governance
1 finding
critical“There were no audits completed by the provider to monitor and assess the quality of the service and ensure the registered manager had maintained effective oversight.”
person centred care
1 finding
moderate“Risk assessments were generic and not developed to meet the specific needs of people... Care plans were copied and pasted with generic information”
communication with families
1 finding
minor“Relatives however did say communication with the office could be improved”
infection control
1 finding
minor“where staff did not wear PPE, a risk assessment to support this decision had not been completed. The registered manager took immediate action to assess this area during the inspection.”
incident learning
1 finding
minor“Staff discussed and reviewed incidents to share lessons learned... However, these were not formally recorded in meeting minutes.”
supervision appraisal
1 finding
minor“Staff felt supervision would be more effective if face to face... 'it would be good to be able to discuss other things face to face.'”
complaints handling
1 finding
minor“Complaints and their outcomes were not shared with staff to help develop staff awareness of knowledge as part of lessons learned.”
end of life care
1 finding
minor“No person at the time of the inspection required end of life care. End of life training was planned to be provided to staff.”