critical“The provider had failed to ensure systems and processes were established and operated effectively at all times to monitor and improve the quality and safety of the service.”
care planning
1 finding
critical“Risk assessment were generic and was not personalised to each person.”
person centred care
1 finding
critical“we found arrangements were not in place to ensure people received care that was person-centred. This was a breach of regulation 9 (Person centred care)”
staff training
1 finding
moderate“staff had not received any training around diabetes care. This meant people were at risk of receiving care from staff who did not fully understand their health conditions.”
supervision appraisal
1 finding
moderate“two staff working for more than 12 months did not have appraisals to support their development and they did not receive regular supervision”
staff competency
1 finding
moderate“There were no formal competency checks in place to ensure staff were competent in all aspects of their role.”
safeguarding
1 finding
critical“The systems and processes to safeguard people from the risk of abuse were not operated effectively.”
incident learning
1 finding
moderate“This meant there was no learning from incidents, or analysis to identify themes and trends and actions taken to prevent reoccurrence.”
record keeping
1 finding
moderate“some records we requested were not easily accessible. Other records we had previously requested from the service had also not been provided”
complaints handling
1 finding
moderate“We were not assured that the provider was capturing and recording all the complaints that had been received.”
leadership
1 finding
critical“There was a lack of provider and managerial oversight of the service.”
cultural competency
1 finding
minor“Care plans did not record people ethnicity and end of life preferences.”
end of life care
1 finding
minor“Information about people's ethnicity and end of life was not recorded”
other
1 finding
moderate“only one employment references which was not in their job application had been requested, and the other reference had not been requested.”
communication with families
1 finding
minor“they could not get in contact with office staff over the weekend and the phone is not always answered.”