moderate“We identified some discrepancies between information held in people's electronic and paper records which the providers quality checking processes had failed to identify.”
critical“Governance arrangements were not effective in identifying shortfalls in the quality of the service... they had failed to undertake any audits or quality assurance checks.”
record keeping
2 findings
moderate“The service was operating with paper based and electronic care records whilst information was being transferred to the new system...discrepancies between information held in people's electronic and paper records.”
critical“There was a failure to maintain an accurate, complete and contemporaneous records. This was a breach of... Regulation 17”
care planning
2 findings
minor“Some care plans were still in the process of being updated and the registered manager had a clear time scale for achieving this.”
critical“Risks to people were not identified and managed... where it was recorded that people had epilepsy or experienced seizures processes were not in place to identify and mitigate associated risks.”
safeguarding
1 finding
critical“Systems and processes were not robust to protect people from the risk of abuse. The provider had failed to identify and mitigate practice that had the potential to expose people to harm.”
medication management
1 finding
critical“Medicines were not always managed safety... The administration of medicines was not always accurately recorded... Medicine risk assessments lacked information about how to mitigate identified risks.”
staff training
1 finding
critical“there were 15 staff without any record of ever having undertaken safeguarding training and there was no record of staff having access to training to meet people's specific needs”
staff competency
1 finding
critical“One staff new to care had completed two of the 15 required standards and had passed their probation period without this being identified. They had been working alone for eight months”
leadership
1 finding
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
incident learning
1 finding
critical“The provider did not have a system in place to monitor or analyse incident records for trends... there were no processes for learning lessons to drive service improvements.”
person centred care
1 finding
moderate“People did not always receive a person-centred approach to having their needs met. Assessments and risks assessments lacked important details”
consent capacity
1 finding
moderate“Processes were not in place to ensure people were not deprived of their liberty for the purpose of receiving care without lawful consent.”
supervision appraisal
1 finding
moderate“Staff told us they did not receive formal recorded supervision on a regular basis or an annual appraisal.”
communication with families
1 finding
moderate“People's communication needs were not always identified or recorded in their support plans. Where a person had a severe communication impairment due to their learning disability this information had not been shared appropriately”
other
1 finding
moderate“Staff were not always recruited safely... appropriate recruitment checks had not been consistently undertaken to ensure staff were safe to work with people.”