critical“No staff had any references recorded and only one member of staff had a criminal background check.”
staff training
1 finding
critical“Staff did not have a comprehensive induction. The provider relied on people's previous experience and shadowing as their method of training.”
supervision appraisal
1 finding
moderate“Staff did not have regular supervisions and had not had an annual appraisal.”
governance
1 finding
critical
“No quality assurance systems were in place. Care plans, medication records and daily notes were not audited or checked.”
care planning
1 finding
moderate“People had care plans in place which reflected their care needs however they were inconsistent.”
end of life care
1 finding
moderate“People had not been asked about their end of life wishes, including any spiritual and cultural needs. Staff had not received any training in end of life care.”
consent capacity
1 finding
moderate“People did not have mental capacity assessments recorded when necessary.”
incident learning
1 finding
minor“The small staff team worked together to discuss what worked best for people however these meetings were not recorded and there was a risk that learning opportunities could be missed.”
record keeping
1 finding
moderate“The registered manager confirmed they visited every person at least once a week however no formal processes were followed and no records were maintained.”