critical“The provider failed to have sufficient systems in place to protect people from abuse and improper treatment. This placed people at risk of harm.”
staffing levels
1 finding
critical“There were not enough staff employed using safe recruitment practices to provide all the care people required to meet their needs.”
staff training
1 finding
critical“Staff did not have the training or skills required to know how to manage people's specific needs such as Parkinson's disease, autism, and seizures.”
governance
1 finding
critical“The provider failed to assess, monitor and improve or mitigate known risks affecting the quality and safety of the service.”
record keeping
1 finding
critical“The provider failed to keep accurate records of people's daily care, rotas, staff employment information, induction, supervision and training records.”
care planning
1 finding
critical“People's care plans were not always reflective of people's current needs. Where people's needs had changed, the provider had not always assessed the risk.”
supervision appraisal
1 finding
moderate“The provider's records for supervisions were not accurate. For one member of staff the supervision dates did not correlate with the dates of employment.”
incident learning
1 finding
critical“The provider did not use their systems to record accidents, incidents, safeguarding concerns or complaints. This meant they did not have the information they required to analyse and learn.”
person centred care
1 finding
moderate“The negative culture within the service meant the provider failed to provide respectful and dignified care to autistic people.”
complaints handling
1 finding
moderate“The provider failed to maintain a log of the complaints they had received or the actions they had taken.”
medication management
1 finding
critical“The medicines audit completed in March 2023 showed medicine records had been reviewed...however, there were no people receiving medicines from staff; the audit was fictitious.”
leadership
1 finding
critical“There was very poor managerial oversight of safeguarding, incidents, complaints, people's records, rotas, staff records and audits.”
staff competency
1 finding
critical“Staff had received safeguarding training but there was no evidence their competency had been checked. Staff failed to do so in practice.”