critical“The registered provider lacked oversight of the service delivery and there were no robust systems and processes to assure the quality of the care provided.”
critical“Records to demonstrate how people's needs were safely met, and to demonstrate consistent management of the service, were not fully in place and were still being updated.”
record keeping
2 findings
critical“continued breaches in relation to people's safe care, staffing, recruitment and good governance, including record keeping”
moderate“Some gaps in care records suggested care had not been provided at times identified; the registered provider explained this was in part down to poor internet connection”
safeguarding
2 findings
critical“The provider's safeguarding policy and procedure had not been reviewed or updated since 2015.”
moderate“systems and processes were not robustly in place to show how people would be protected from financial abuse and how staff are protected against allegations.”
medication management
2 findings
critical“There was no evidence staff had been observed or assessed as competent to support people with medicines. This had been reported on at the last inspection, with no action taken to improve.”
moderate“where one person's MAR chart was handwritten, this was done by only one member of staff. Two members of staff checking this record would ensure the transcription of the medicine was accurate.”
care planning
2 findings
critical“Individual risk assessments were not always completed or lacked information for staff to support people safely.”
minor“Care plans were in the process of being improved using new person-centred documentation... This was work in progress at the time of the inspection.”
staff training
1 finding
critical“some staff had undertaken training in the form of e-learning, but this was insufficient to ensure all staff had the necessary skills to support people with their specific needs”
staff competency
1 finding
critical“There was no evidence of any competency checks carried out to ensure staff were able to safely provide care.”
supervision appraisal
1 finding
critical“There was an absence of staff supervision records in the five staff personnel files we saw, and staff supervision was not delivered in line with the company's policy of six times per year.”
leadership
1 finding
critical“The provider was not able to demonstrate the competency required to carry on and manage the regulated activity.”
infection control
1 finding
moderate“At the last inspection, no staff had completed infection prevention and control training. At this inspection, only two staff had completed this training.”
incident learning
1 finding
critical“The provider had been in breach of regulations at the last inspection, although there was limited evidence of action taken to drive improvements.”
other
1 finding
critical“Recruitment procedures were not followed and staff were employed without any evidence of interview or suitability checks carried out.”
consent capacity
1 finding
moderate“not sure how people's mental capacity was determined other than as part of the initial referral information received”
communication with families
1 finding
minor“People did not receive a scale of charges or a contract to show how much they paid for their care.”