moderate“Risk assessments did not have sufficient detail of how to manage all potential risks such as managing catheter care, manual handling and assessing risks in the environment.”
minor“there was no detailed guidance as to the timescale when emergency support should be requested. The registered manager told us they would review and make clear the protocol to be followed by staff.”
staff training
2 findings
moderate“Not all staff had received detailed training in important issues such as manual or handling and personal care.”
minor“Audits undertaken by the registered manager had identified staff had not completed all training required.”
staffing levels
1 finding
critical“A staff member with a past record did not have a risk assessment in place to outline the risks of the person providing personal care”
governance
1 finding
critical“The provider failed to learn and monitor the quality and safety of care. This was a breach of regulation 17 (Good Governance)”
record keeping
1 finding
critical“A relevant reference of previous care employment had not been requested. This put people at risk of receiving care from unsuitable staff.”
medication management
1 finding
moderate“There were a number of gaps in records which had not been explained. No audits were in place for medicines.”
supervision appraisal
1 finding
minor“Supervision had been limited due to the pandemic. The registered manager said this would be provided more frequently in future.”
incident learning
1 finding
moderate“Records were not always clear what follow-up action had taken place with regards to issues. There were no lessons learnt information in place.”