critical“The provider had failed to ensure the quality assurance processes in place were effective. We found limited evidence of effective audits and there was no service improvement plan in place.”
medication management
1 finding
critical“Medicine audits were not robust enough to demonstrate good governance. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
record keeping
1 finding
moderate“We found the provider was not consistently documenting all actions taken. There were gaps in care documentation, a lack of recording supervision inconsistent auditing and a lack of oversight of renewing training.”
staff training
1 finding
moderate“Some training such as safeguarding and infection control was not renewed therefore we were not assured staff knowledge remained current.”
supervision appraisal
1 finding
moderate“The provider could not evidence effective support was in place for staff. Although staff told us there was regular supervision, this was not always documented.”
care planning
1 finding
moderate“People's care plans identified general support needs; however, we found specific information missing. For example, records lacked details on how to hoist someone and what sling to use.”
complaints handling
1 finding
moderate“There was limited oversight of complaints. There was a complaints log which lacked details and actions taken following complaints were not always documented.”
staff competency
1 finding
minor“The provider ensured all staff who administered medicines were trained to do so and had frequent competency checks. However, these were not always documented.”
incident learning
1 finding
minor“The provider had systems in place to identify lessons to be learnt. The provider held monthly meetings with staff to share lessons learnt. However, this was not always documented.”