critical“Staff had used unlawful restraint on a person, and this had not been reported. A Staff member told us that a person was forced to sit on the toilet after they communicated with staff that they didn't want to.”
critical“There had been a serious incident of verbal abuse between 2 people...This had not been appropriately reported...The local authority and CQC had not been informed.”
medication management
2 findings
critical“One person's MAR was blank for the last entry and we observed there to be none of this medication in stock. During our medicine count we found one person had 8 tablets missing with no explanation.”
moderate“They weighed below 50kg and the provider had not followed NHS choices guidance 'How and when to take paracetamol for adults'...The person's dose had not been checked.”
care planning
2 findings
moderate“One person's care and support plan had not been reviewed since August 2021. People's PBS plans did not consistently reflect people's most up to date needs.”
moderate“Staff had written 'personal care given' but they had not detailed what they had supported with...A person's mental capacity assessment was missing the best interest section.”
governance
2 findings
critical“Robust governance systems and processes were not in place to identify issues. Quality assurance audits had not highlighted the errors we found during inspection, including 'as required' medicines not being available.”
moderate“The service was required to have a registered manager in post. The previous registered manager had deregistered in June 2023. No applications to register a new manager had been received.”
incident learning
2 findings
critical“Incidents of unlawful restraint were not recorded. The registered manager could not be assured that learning from these incidents could be implemented to reduce the likelihood of reoccurrence.”
moderate“The provider and management team understood their role...had notified CQC about events that had occurred apart from one allegation of abuse which was reported retrospectively.”
record keeping
2 findings
moderate“Daily records did not corroborate what staff had told us or reflect people's current needs. Daily notes for some people included '[person] woke up with an attitude', '[person] put on the seizure'.”
minor“Person centred fire risk assessments...contained generic guidance...Personal emergency evacuation plans (PEEPs) did not provide all the information staff needed to understand how to safely evacuate people.”
staff training
1 finding
critical“Staff told us they had not completed face to face MAPPA training. One staff member told us they had not received epilepsy training and they didn't know if the person had any medicines for this.”
person centred care
1 finding
moderate“One person told us they would like to set some goals but were unsure where to start and had not been supported by staff to do so. One person had not been weighed since being supported by this provider.”
leadership
1 finding
critical“The registered manager had also failed to pick up on the abuse that people had been subjected to within the service. Staff told us they did not always feel supported by management.”
complaints handling
1 finding
minor“One relative told us of a complaint they had made but were unaware of the outcome. The service had investigated the complaint but had failed to fully convey and involve the relatives with the outcome.”
staff competency
1 finding
critical“The skills of staff did not always match the needs of the people using the service. One staff member was just shown what to do by another staff member regarding MAPPA.”
supervision appraisal
1 finding
moderate“The registered manager carried out competency assessments for staff however these were not always effective when highlighting the lack of support staff felt.”
infection control
1 finding
moderate“One room we observed there to be no toilet seat on the persons toilet. Other rooms we visited were visibly unclean and odorous.”
consent capacity
1 finding
critical“The service was not always working within the principles of the MCA. People were subjected to unlawful restraint and a person was forced to sit on the toilet after they communicated they didn't want to.”