minor“we found instances of language used by staff that still did not demonstrate best practice. For example, describing people's behaviour as 'aggressive'”
minor“We did find some records that would have benefited from more detail however, other records showed the management team were making regular checks of incidents”
moderate“Some incidents had not been recorded at all, so there was no information to review and learn from.”
incident learning
3 findings
moderate“staff were not consistently following one person's PBS plan; in terms of when to give medication to manage their distressed behaviours.”
moderate
“Some incidents had not been recorded at all, so there was no information to review and learn from.”
moderate“Gaps in records such as incident reports, showed missed opportunities to routinely learn lessons and improve safety across the service”
medication management
3 findings
minor“we did find some [PRN protocols] that would benefit from further detail to ensure consistency in how people's medicines were administered”
critical“Medicines were not always managed safely or administered as prescribed.”
critical“We saw medication in one person's flat at 3.30pm, which was due to be given at 2pm.”
care planning
2 findings
moderate“there were still entries that lacked personalised information and read as a list of tasks carried out by staff”
moderate“Support plans did not contain sufficient guidance to ensure people consistently received personalised, proactive and co-ordinated support.”
person centred care
2 findings
moderate“Staff had identified potential goals for people however there was little evidence of people's involvement, progress, or measurable steps to achieve the goals.”
critical“People did not consistently receive care that supported their needs, aspirations, focused on their quality of life, and followed best practice.”
communication with families
2 findings
moderate“mixed feedback about how the provider sought feedback from people and those important to them...Other people told us they were not asked for their feedback.”
moderate“Staff could not effectively communicate with everyone using the service, because they did not have the right guidance and skills to understand some people's individual communication needs.”
staff training
2 findings
moderate“Further work was needed to ensure all staff had the skills to communicate with and understand people who had individual ways of communicating such as Makaton”
moderate“Training records we saw had lots of gaps for both new and refresher training.”
governance
2 findings
moderate“there was a greater focus on policies and processes, rather than people's lived experience and quality of life...provider's audits still not fully match our inspection findings.”
critical“The provider's systems for checking the culture, quality and safety across the service were not sufficiently robust.”
staff competency
2 findings
moderate“we did not see any communication aids or signing being used with people during our visits, and daily records made little reference to these too.”
moderate“The service had enough staff, but they were not always appropriately skilled to meet people's needs and keep them safe.”
infection control
2 findings
critical“The service did not have effective infection, prevention and control measures to keep people safe.”
critical“we found an unacceptable level of dirt, including faeces, in one person's flat and on their duvet cover.”
safeguarding
1 finding
critical“records showed there had been delays in some safeguarding concerns being reported in a timely way; both to us (CQC) and the local authority safeguarding team.”
consent capacity
1 finding
critical“People were not consistently supported to make decisions in line with current legislation and guidance.”
supervision appraisal
1 finding
moderate“We also received mixed feedback about how regularly staff supervisions were carried out. We were unable to verify this information as the supervision matrix we saw was not up to date.”
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.”
complaints handling
1 finding
moderate“Records did not evidence how concerns and complaints were handled.”