critical“they had failed to report them to the local authority in accordance with procedures, for further investigation and follow up.”
governance
1 finding
critical“Systems to assess and improve the quality and safety of the service were ineffective. This was a breach of regulation 17 (Good Governance)”
staffing levels
1 finding
critical“staffing rotas which demonstrated people did not receive their commissioned support hours.”
staff training
1 finding
critical
“there were significant gaps in the training some staff had undertaken and some staff had not completed an induction in line with the Care Certificate Standards.”
consent capacity
1 finding
critical“This lack of understanding had led to one person having restrictions placed upon them without legal authorisation.”
medication management
1 finding
moderate“Medication administration records (MAR) showed three gaps in one person's records where we could not tell if the medicines had been given.”
care planning
1 finding
moderate“information gathered as part of one person's pre assessment process did not form the basis of their risk assessments.”
incident learning
1 finding
moderate“this information was not being analysed or reviewed. This meant the provider could not be assured that lessons had been learnt”
record keeping
1 finding
moderate“Some care records were not always accurate and had not always been updated to reflect changes in people's needs”
person centred care
1 finding
moderate“we observed some practice which did not always demonstrate a person-centred approach and was not in keeping with best practice guidance.”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”