moderate“Whilst the provider was immediately responsive to issues identified during the inspection such as the locked fruit bowl and potential safeguarding, the internal systems had not identified these.”
critical“Systems to monitor the quality and safety of people's support were not effective. There was a breach of regulation 17 (Good Governance)”
safeguarding
2 findings
moderate“We identified one potential safeguarding issue that had not been raised using the internal system and as a result was at risk of being missed.”
critical“we identified two situations that had occurred in the six months prior to our visit that should have been considered as safeguarding concerns.”
staffing levels
2 findings
moderate“Relatives, and staff, observed an improvement but we heard there was still an impact on people due to high agency use.”
critical“The service had been experiencing a chronic shortage of staff... There were not sufficient staff to meet people's assessed needs.”
leadership
2 findings
moderate“Staff at one location felt less supported. They attributed this to the vacancy in the leadership of this location and gave examples of the impact.”
moderate“a lack of leadership and oversight meant that people's support was not always effective and consistent.”
other
2 findings
minor“We noted that a fruit bowl had been locked away in one house and this was not covered by the oversight of restrictions.”
moderate“Statutory notifications had not always been made to the CQC... Notifications regarding the outcome of a deprivation of liberty and allegations of abuse had not been made.”
infection control
1 finding
minor“When we first visited one home staff were not wearing masks when in close proximity to the people they supported. This was addressed immediately.”
consent capacity
1 finding
critical“The MCA was not used as a framework to ensure people's best interests were always reflected or that they had consented to their care.”
person centred care
1 finding
critical“People's support was not provided within a framework that ensured consistency in person centred support.”
staff training
1 finding
critical“People were supported by staff who had not always undertaken appropriate training. The training around autism had not been mandatory and most staff had not completed it.”
supervision appraisal
1 finding
moderate“Staff had not been receiving regular supervision sessions due to the issues with ensuring staff numbers.”
care planning
1 finding
moderate“Care plans and people's written records were not the main source of agreed information for staff and there were risks associated with this.”
incident learning
1 finding
moderate“Incidents had not been appropriately monitored and analysed to ensure lessons were learned.”
communication with families
1 finding
moderate“Relatives commented on not being sure who they should speak with and difficulties with communicating.”
record keeping
1 finding
moderate“There were gaps in these records and staff and professionals described the impact of these gaps in ensuring people received the right support.”