critical“The provider did not monitor late calls to people living in their own homes. Therefore, we could not be assured people were receiving care as planned.”
critical“Staff and relatives felt staffing levels were poor. "We are firefighting, the priority has to be keeping staff and service-users safe."”
governance
2 findings
critical“Systems were not yet robust enough to demonstrate good governance. This placed people at risk of harm. This was a continued breach of regulation 17.”
minor“There was no overview of complaints in the service...the new computer system which was yet to be fully embedded, would in the future provide an overview of reports so any trends and patterns could be more easier identified.”
medication management
2 findings
minor“People had medicine support plan and protocols describing when they should be offered some of their 'when required' medicines however we found some documentation lacked details.”
minor“Some improvements were needed to fully ensure the safe management of medicines. The management team took prompt action to ensure the concerns were addressed by the end of the inspection.”
supervision appraisal
1 finding
moderate“Recent management changes meant there were gaps, for example with supervision and surveys however there was evidence these were being addressed.”
infection control
1 finding
moderate“One of the supported living houses we visited was unclean and although we saw evidence of cleaning records there was not enough time allocated.”
care planning
1 finding
minor“We found some guidance for these medicines was in place but this needed more personalisation regarding people's individual needs for these medicines.”
record keeping
1 finding
minor“Some recruitment records were not immediately available at the location office as they were held at the provider's head office. They were obtained during the inspection.”
incident learning
1 finding
minor“A new system was in place to provide overview of accidents, incidents and safeguarding concerns. This had not been fully embedded but would provide reports to identify any patterns and trends.”
person centred care
1 finding
minor“One relative told us they did not think their family member was encouraged to be as independent as they could be.”
communication with families
1 finding
minor“Another relative did not have confidence and felt there was poor communication from the management team.”