moderate“The auditing sheet to check that the provider's recruitment policy had been followed, had not been completed for any of these 3 staff.”
minor“we noted that, in places they needed to refer to the terminology used in new Care Act 2014”
staffing levels
1 finding
critical“None of the 3 staff files we selected contained any references. This included staff who had previously worked in social care and for whom it is required suitable references are obtained.”
governance
1 finding
critical“The provider had failed to ensure there were adequate systems to assess, monitor and improve the quality and safety of service provided. This was breach of Regulation 17.”
complaints handling
1 finding
critical“The provider had failed to operate an effective system for identifying, recording and responding to complaints. This was breach of Regulation 16.”
medication management
1 finding
moderate“Staff did not always observe them taking their medicines after they had given them to them. A person told us, 'Staff only watch me occasionally to make sure I have taken my tablets.'”
staff competency
1 finding
moderate“Neither were staff's practical moving and handling skills observed as part of spot checks to ensure staff were following guidance and safety protocols.”
care planning
1 finding
moderate“There was a lack of detailed guidance for staff about how to support people who used a catheter. Staff were not advised of the signs or symptoms of an infection so they knew when to seek medical advice.”
staff training
1 finding
moderate“Staff were provided with catheter care training at induction. However, there was no programme to refresh staff's knowledge through updated training or an assessment of their competency.”
incident learning
1 finding
moderate“When concerns had been raised there was inadequate monitoring to ensure the chance of the same thing happening again had been minimised.”