critical“There was not enough information about some risks people were exposed to or how these should be managed. For example, one person regularly became physically aggressive causing harm to themselves, staff and others.”
medication management
1 finding
critical“Not all staff who supported people with their medicines were trained to do so. The medicines assessments were incomplete and did not give enough detail about risks.”
staff competency
1 finding
critical“Staff had not been trained to understand these. For example, some people had epilepsy...The staff had not had the training to understand how to support people in the event they had a seizure.”
staff training
1 finding
critical“Since July 2022, all health and social care providers have been required to ensure staff received training on learning disabilities and autism. This training had not taken place.”
staffing levels
1 finding
critical“Failure to ensure there were sufficient numbers of suitably qualified and experienced staff to meet people's needs was a breach of Regulation 18 (staffing).”
supervision appraisal
1 finding
moderate“Staff were not always given the supervision they needed to discuss their work and to ensure they had the knowledge and skills to care for people safely.”
governance
1 finding
critical“The provider has been in breach of legal requirements at 8 of the 9 inspections we have undertaken since they were registered in 2014.”
record keeping
1 finding
moderate“Some monitoring records were inaccurate and therefore could not be relied upon. Records of spot checks on staff recorded their compliance with tasks they were not assigned to carry out.”
incident learning
1 finding
critical“They recorded some incidents, but not all of these and did not record when staff used restraint or restrictive practices. Failure to record these meant the incidents were not investigated.”
person centred care
1 finding
moderate“Care plans were not always detailed enough about people's individual needs or how they should be cared for. Some people had complex care packages...There was not enough information.”
consent capacity
1 finding
moderate“Records did not always clearly show how decisions had been made or consent obtained.”
communication with families
1 finding
moderate“People were not always supported with their communication needs. Some people could not use speech. The staff had not been trained to understand how to communicate effectively.”
safeguarding
1 finding
critical“Staff sometimes restrained people but there were no plans for this, the staff had not been trained to do so safely and the provider did not investigate, reflect on or analyse these incidents.”