critical“The provider had failed to have a system in place to monitor and have oversight over the quality and safety of the service.”
critical“Audits were not effective, as action had not always been taken to address the shortfall identified. Omissions in daily records and medicine records had been highlighted but had not been addressed.”
record keeping
2 findings
moderate“Some moving and handling risk assessments were out of date and individual infection control risk assessments had not been reviewed.”
critical“The registered manager was unable to provide recruitment information for two of the staff. This meant we were unable to determine whether appropriate checks had been carried out.”
care planning
2 findings
moderate“Care plans were not audited to ensure they were consistent with the care delivered. We found one care plan had not been reviewed as agreed.”
critical“People did not have risk assessments which guided staff about how to keep them safe. For one person living with diabetes, there was no diabetes care plan or risk assessment available.”
incident learning
2 findings
moderate“Accidents and incidents were recorded individually. However, they had not been reviewed to identify trends and enable learning through the service.”
critical“Accidents and incidents were not always recorded or investigated. This meant that investigations did not always take place to ensure all remedial actions were taken.”
staff competency
1 finding
moderate“One member of staff's file did not contain their full employment history as required. References had been received for staff however, it was not always clear who had supplied the reference.”
infection control
1 finding
minor“Some people told us that staff did not always wear their face masks as required by the service.”
medication management
1 finding
critical“Medicine Administration Records did not include sufficient information to ensure that people received their medicines as prescribed. For example, there were gaps in recording.”
consent capacity
1 finding
critical“Documentation to support decision-making in line with the MCA was not in place. The registered manager's responses were not in line with the framework of the MCA.”
staff training
1 finding
moderate“Staff did not receive training in topics which reflected the needs of the people they supported. Examples included catheter care, diabetes and pressure area care.”
complaints handling
1 finding
moderate“The complaint had not been formally recorded, investigated or responded to in line with the providers' complaints policy. The registered manager told us they had not received any complaints.”
leadership
1 finding
critical“The registered manager did not have a good understanding of their regulatory responsibility and legal requirements. There were two ongoing breaches of regulations identified at the previous inspection.”
cultural competency
1 finding
moderate“Documentation did not reflect details about people's protected characteristics and the registered manager did not have a good understanding about how to ensure people did not receive discriminatory care.”