critical“The provider had failed to operate effective governance systems... audits of care records and risk management plans were not recorded, and any checks completed had not identified the shortfalls we found.”
safeguarding
1 finding
moderate“The provider's safeguarding policy did not reflect the Local Authority guidelines and was not sufficiently detailed to support staff in the event of an allegation of abuse.”
care planning
1 finding
moderate“care plans were not sufficiently detailed, or individualised to ensure people received consistent and personalised care by the staff supporting them.”
medication management
1 finding
moderate“Staff told us they had applied an unprescribed cream to a person's skin. There was no care plan or arrangements in place to ensure the safe management of creams.”
infection control
1 finding
moderate“The provider had an infection, prevention and control policy but this had not been kept updated with government guidelines to help ensure staff followed safe practice.”
staff competency
1 finding
moderate“People were supported by trained staff, but records had not been maintained of staff competency checks to show staff had learned from their training.”
record keeping
1 finding
moderate“assessment records were not clearly recorded to show people's needs had been identified for these to be incorporated into care plans.”
other
1 finding
moderate“recruitment processes were not sufficiently robust to demonstrate all staff working for the service had completed the necessary checks to support people safely.”
communication with families
1 finding
minor“People's communication needs, and preferences were not always assessed or documented to show if people needed any support and to ensure staff supported people effectively.”
complaints handling
1 finding
minor“A complaints policy was in place, but the investigation process was not sufficiently detailed to show what people should expect if they raised a complaint.”
end of life care
1 finding
minor“Care plans did not show people's end of life wishes.”
incident learning
1 finding
moderate“The provider's systems and processes were not sufficiently embedded to enable areas of improvement to be identified and acted upon.”