critical“There had not always been enough staff to meet people's needs... sufficient staff had not been available to provide two care staff to attend to this person's needs on all their required care calls.”
governance
1 finding
critical“Systems and processes were not operated effectively to assess, monitor, reduce risk and improve the quality and safety of services. Records were not always accessible, complete, contemporaneous, and accurate.”
staff competency
1 finding
critical“Recruitment procedures were not established and operated effectively to ensure person's employed met the conditions and required recruitment checks.”
infection control
1 finding
critical“Care staff were not wearing face masks or testing for COVID-19 in line with the latest government guidance... Infection risk assessments were not in place.”
medication management
1 finding
critical“Medicines administration record (MAR) charts were not available... Older MAR charts had not always been filled in to say medicines had been offered.”
staff training
1 finding
critical“Care staff had not been trained to have the skills and experience to reduce risks from COVID-19. The provider told us staff had not had training in COVID-19 other than being sent a booklet on it.”
supervision appraisal
1 finding
critical“There was no evidence care staff had supervision every three months. This meant staff development was not recorded and tracked.”
care planning
1 finding
moderate“Risk assessments had not been kept under review... the risk assessment for one person at risk of falls had last been updated in 2021.”
complaints handling
1 finding
moderate“There was no system to record concerns and complaints and monitor them to ensure the provider's complaints policy was followed and effectively operating.”
incident learning
1 finding
moderate“Records did not provide enough detail to help identify learning when things went wrong.”
leadership
1 finding
critical“Resources to run the service in the provider's absence were not available. The provider had not ensured there was an effective contingency plan in place for when they were absent.”
record keeping
1 finding
critical“The provider had not operated an effective system to ensure people's care records, including those for their medicines administration were accurate, complete and contemporaneous.”