critical“Care was not always provided with the consent of service users... they experienced restrictions on their choices and care.”
staff training
1 finding
critical“Care staff had not received training that provided them with the skills and competence to safely manage and reduce risks to people when they expressed some behaviours”
staff competency
1 finding
critical“Care staff providing care to service users with behaviours that could place themselves and others at risk did not always have the competence and skills to do so safely.”
medication management
1 finding
moderate“one person told care staff they were in pain and they were not offered any pain relief medicine until the following day”
governance
1 finding
critical“The provider had failed to ensure systems and processes were operated effectively to improve the quality and safety of care.”
incident learning
1 finding
moderate“Reviews of incident forms had not identified common trends and therefore possible improvements to people's quality of care had not been explored further.”
safeguarding
1 finding
moderate“Care staff had been trained in safeguarding... However, they had not recognised when some of the people they cared for had restrictions on their freedom.”
infection control
1 finding
moderate“We were not fully assured that the provider was using PPE effectively and safely. One member of staff told us they did not wear a face mask”
supervision appraisal
1 finding
minor“Random people from the office ring and give supervision.”
person centred care
1 finding
moderate“Managers and leaders had not consistently developed a culture that promoted person centred outcomes, seeking people's consent and respecting people's choices.”
record keeping
1 finding
critical“Statutory notifications had not been submitted for these two incidents. The provider's systems had not identified these notifications had not been sent as required.”
care planning
1 finding
moderate“Care plans and risk assessments for behaviours that could place people and others at risk of harm did not effectively assess risks and did not identify effective ways to reduce risks.”