critical“We found no evidence of provider oversight or auditing. This meant gaps in the day-to-day governance and auditing systems within the service had not been identified by the provider.”
staffing levels
1 finding
critical“Gaps in recruitment checks, records and references had not been addressed. The provider had not completed recruitment risk assessments to ensure staffs suitability to work with vulnerable adults.”
staff training
1 finding
critical“Staff compliance with the provider's training schedule was inconsistent and we found gaps in aspects of training, including falls management and dementia.”
supervision appraisal
1 finding
critical“The provider had failed to ensure staff received appropriate support, training, professional development and appraisal. This was a breach of Regulation 18(2)(a).”
medication management
1 finding
moderate“When people had been identified as needing their medication to be administered covertly, there were no records or plans evidencing approval from the GP.”
missed or late visits
1 finding
moderate“People's call monitoring logs and daily records evidenced calls were not carried out at the scheduled times agreed in people's care plans.”
care planning
1 finding
moderate“The quality of people's care plans was inconsistent. In other areas of care plans, person-centred and detailed information was lacking.”
consent capacity
1 finding
moderate“The provider did not always evidence when people's capacity had been assessed in line with the MCA. People's capacity had not been assessed in a decision or time specific way.”
incident learning
1 finding
moderate“We found no evidence the provider was carrying out analyses of accidents or incidents to identify areas for improvement.”
complaints handling
1 finding
moderate“One relative told us they had made several complaints to the registered manager in relation to late calls. They stated no improvements had been made.”
record keeping
1 finding
minor“Information relating to communication with external professionals was not always recorded in people's care records.”
end of life care
1 finding
minor“At the time of our inspection there was no evidence staff had completed end of life care training.”