moderate“the risk assessments did not include full step by step guidance for staff on what action to take if the risks occurred. For example, if someone started to choke or had a seizure.”
minor“Recruitment records were not all kept together. One staff recruitment file only contained one reference; the other reference was at the providers central office.”
moderate“where recommendations had been made by professionals, these had either not been implemented or where they were, had not been sustained.”
record keeping
2 findings
moderate“Some documentation lacked information and specific detail. Although this did not have a direct impact on people there could be a risk staff that were new or unfamiliar with people would not have the guidance”
moderate
“Personal emergency evacuation plans (PEEPs) did not include specific information to instruct staff on how to support people in an emergency.”
care planning
1 finding
moderate“Care plans were cumbersome and contained a lot of information that made it difficult for staff to easily find the relevant information they needed.”
safeguarding
1 finding
moderate“there had been a safeguarding incident which had not been reported immediately to the registered manager. This caused a delay and meant action to keep people safe was delayed.”
medication management
1 finding
minor“There had recently been a medicines error. This was fully investigated and the reason for the error identified.”
complaints handling
1 finding
minor“the meeting in September 2022 had identified that complaints were not being recorded well although staff were responsive in resolving any concerns people had.”
leadership
1 finding
moderate“The management of the service had been inconsistent... managers had not always been responsive to concerns raised.”
communication with families
1 finding
moderate“health and social care professionals who work with the service told us the communication and responsiveness from the service was poor.”
supervision appraisal
1 finding
moderate“Staff told us supervisions and one to one meetings were not as regular as they could be and at least one supervision had been done by a peer, rather than a manager.”
staffing levels
1 finding
minor“The service had a high turnover of staff and new staff had joined the service recently. The service still had vacancies for support staff”
incident learning
1 finding
minor“The service had systems in place to encourage lessons to be learned and shared after incidents or accidents, but this wasn't always robust enough”
other
1 finding
moderate“Staff told us the culture of the service within the staff team was poor, using terms such as 'toxic', 'hostile' and 'bullying'.”