moderate“Records of injuries were not fully recorded. We found no information recorded regarding position, size, colour or shape of injury.”
minor“some of the documents we requested were hard to find. The manager told us, 'I've not been here that long, but it was clear to me I need to reorganise the office.'”
medication management
2 findings
moderate“When people had 'as required' (PRN) medicine prescribed, there were no PRN protocols in place to advise staff on when the medicine should be administered.”
minor“we could not find protocols to ensure the safe administration of 'as required' medicine (PRN). We informed the manager who said they would take action to resolve these concerns.”
staffing levels
2 findings
minor“Staff do not always turn up on time due to not having enough travel time between visits.”
minor“I think the staffing levels seem to fall short at the weekends where staff feel pushed, but care calls are met.”
care planning
1 finding
critical“Risks had not always been assessed or mitigating strategies implemented. In all 3 people's care records we reviewed we found risks surrounding people's health conditions and medicines had not been fully assessed.”
safeguarding
1 finding
critical“Records evidenced that one person had told staff of a potential safeguarding concern. Managers had not informed the local safeguarding team.”
incident learning
1 finding
moderate“Incidents and accidents recorded did not always have an investigation completed to identify any risks, trends or patterns.”
staff training
1 finding
critical“Staff did not have training on supporting people living with dementia or diabetes, and some staff had not completed their training before supporting people.”
governance
1 finding
critical“Audits had not been completed regularly and had not identified the issues we found with missing or incorrect information in care planning documents.”
staff competency
1 finding
critical“We found no references had been sought for 1 staff member who was working with people... Another staff member had not had an updated DBS check.”
consent capacity
1 finding
moderate“The manager had not identified when a relative who did not have the legal power to do so was signing consent for people.”
supervision appraisal
1 finding
moderate“Not all staff had received a spot check to check if staff were working in a safe, person-centred way or if they were following policies and procedures.”
communication with families
1 finding
minor“One person said, 'I feel there is a lack of organisation and communication between the office, manager, the care staff and me.'”