moderate“People had care and support plans that were not personalised, holistic, strengths-based and did not reflect their needs and aspirations.”
critical“Risks to people continued not to be fully managed and mitigated. Risk assessments were not always in place when there were risks to people.”
moderate“one person's care plan stated they should be weighed weekly, however we saw from records they were weighed monthly.”
consent capacity
3 findings
critical“There was a stairgate in use at the service, restricting people's movements but staff, including the new manager, didn't know why this was in place and if people had consented to it.”
critical
“Capacity assessments and best interest decisions were still not always completed when required.”
critical“one person required a best interest decision specific to leaving the service. This had not been carried out.”
staffing levels
2 findings
critical“provider told us 2 staff were needed for a safe fire evacuation, but we observed multiple periods where only 1 staff member was working. This put people at a continued risk of harm.”
moderate“work was still required to establish people's individual hours and ensure they received these. Further oversight was needed of the rota to ensure there was sufficient staff at all times.”
governance
2 findings
critical“The provider had failed to notify the CQC of notifiable events and incidents in a timely manner. Additionally, they had failed to submit their Provider Information Return as required.”
critical“Auditing systems were now in place, however they needed to be developed and sustained...this was the third consecutive inspection that a breach of regulation 17 had been identified.”
person centred care
2 findings
moderate“People did not receive person-centred care. Staff told us they did not have the time to provide personalised care and were task focused.”
moderate“further work was required to ensure people received fully individualised care and their skills were supported.”
record keeping
2 findings
moderate“Information and records relating to people's needs were not accurate or reviewed regularly. This meant people were receiving inconsistent care, sometimes contrary to specialist advice.”
moderate“The provider had not always kept contemporaneous, up to date, accurate records.”
medication management
2 findings
moderate“we observed on one occasion a person not received medicines in line with the prescriber's instruction and some records had not been completed in line with best practice.”
critical“there continued to be times when there was not staff on duty suitably trained to administer emergency medication to people in line with their care plans.”
safeguarding
1 finding
critical“Staff had not had training on how to recognise and report abuse. We found multiple incidents which had not been identified as safeguarding concerns and reported by staff.”
staff training
1 finding
critical“Staff had not received training in topics which had been highlighted by the provider as mandatory, such as fire safety, safeguarding and challenging behaviour.”
leadership
1 finding
critical“The service had indicators of a closed culture, this put people at increased risk of harm. Managers and staff failed to identify poor practice and safeguarding concerns.”
incident learning
1 finding
critical“Staff did not appropriately identify and record incidents which occurred at the service. Lack of management oversight meant incidents we identified during inspection had not been identified.”
infection control
1 finding
moderate“Clinical waste such as used Personal Protective Equipment (PPE) was still not being disposed of correctly. Staff we spoke with were not aware of the process to do this safely.”
supervision appraisal
1 finding
moderate“Staff had not consistently received support in the form of continual supervision and appraisals. However, staff had very recently started to receive supervision following a new manager in post.”
communication with families
1 finding
minor“The service had not fully implemented the Accessible Information Standard to identify, record, flag, share and meet the information and communication needs of people with a disability.”