critical“Prescription medicines for people were not always in stock and no action had been taken by staff to rectify this.”
critical“Medicine administration records were not always accurate or up to date. They did not always reflect people's current prescription medicines.”
safeguarding
2 findings
critical“Incidents and potential safeguarding concerns had not always been dealt with appropriately. Issues were not always escalated in a timely manner.”
critical“We found 1 occasion where staff failed to seek medical attention or take appropriate action following an incident.”
care planning
2 findings
moderate“Support plans did not promote strategies to enhance people's independence and did not contain clear pathways to future goals and aspirations.”
moderate“Assessments of people's needs were not always up to date and did not always reflect the person as a whole.”
staffing levels
1 finding
critical“There were not always enough staff to provide person-centred care. One person required 2:1 support in the community. Activities and outings for this person were limited.”
staff training
1 finding
moderate“The provider had identified one person would benefit from 'intensive interaction'. This training need was highlighted in July 2022. The provider had not sourced this training for staff.”
staff competency
1 finding
critical“The provider did not provide staff with the appropriate and relevant guidance and information to enable them to support people in a safe and person-centred way.”
governance
1 finding
critical“Quality assurance systems and processes were ineffective. Audits and oversight failed to identify most of the issues identified on inspection.”
incident learning
1 finding
critical“There was limited analysis of incidents. There was no evidence of trends and triggers being identified. Incidents were not always investigated robustly.”
person centred care
1 finding
critical“People's social needs were not met, and people were not supported with appropriate stimulation. People were not consistently supported to enjoy hobbies and interests.”
consent capacity
1 finding
critical“People were deprived of their liberty, but the provider did not have copies of, and had not seen, the relevant legal authorisations.”
infection control
1 finding
moderate“Soiled linen was carried into the kitchen without being bagged. This created a risk of cross contamination.”
record keeping
1 finding
moderate“Medicine records and records for the application of creams did not match, and it was not possible to identify which staff member had applied people's creams.”
communication with families
1 finding
moderate“We weren't told about a change in medication; we only found out by accident.”
leadership
1 finding
critical“Neither the provider nor the registered manager were alert to the culture within the service. They had not been pro-active in identifying the shortfalls in care.”