moderate“some of these required updating to ensure the information was accurate and reflective of people's current needs.”
moderate“Health action plans had not been consistently reviewed and updated.”
minor“there was some evidence of goal setting in care plans, however, this required further work to ensure each step of the goal was documented and updated with progress and achievements.”
minor“Goals did not yet fully reflect people's personal aspirations and wishes however, and some of the information was out of date.”
moderate“individual goals and aspirations were not always updated in people's support plans...a communication passport in place but this had not been reviewed since 2013 and contained information that was no longer relevant.”
critical
“conflicting information in their file about the use of thickeners in drinks, making it unclear whether the person needed thickeners or not to keep them safe when drinking”
governance
4 findings
moderate“The quality assurance system had been reviewed and new processes implemented. This required time to embed to ensure it was robust in identifying and addressing shortfalls of the service.”
critical“governance systems are still not adequately robust, and further improvements are needed to meet all legal requirements and to drive continuous improvement.”
critical“Soon after the last inspection in August 2018, the registered manager left. Since that time there has not been a registered manager at the service. This is a breach of the provider's conditions of registration.”
critical“quality monitoring arrangements needed to be strengthened… anomalies between the care records being held in the provider's office and those being maintained in people's own homes”
record keeping
3 findings
moderate“not all risk assessments had been reviewed regularly. For example, for one person a risk assessment for a health condition contained the date of January 2019 of review.”
moderate“legibility and accuracy of some records...Some records did not adequately demonstrate people's involvement or explain how the expenditure was in their best interests.”
critical“epilepsy support plan which did not fully incorporate the most recent consultant neurologist's advice; in terms of the actions to be taken by staff, including the dosage and frequency of recovery medicine”
medication management
3 findings
moderate“Handwritten entries were not dated and signed by two members of staff to confirm they were accurate and up to date. This created a risk that medicines records were not accurate.”
minor“Some protocols for medicines prescribed to be given on a when required basis lacked personalised information.”
moderate“there had been a number of medicine errors across the service… variations between the different supported living settings in terms of the accuracy and quality of Medication Administration Records”
staffing levels
3 findings
moderate“Some relatives told us they felt concerned about the high use of agency staff...there were several new staff who had been successfully recruited...and a total of six staff vacancies.”
moderate“there were approximately 46 support worker vacancies. One person told us, 'We are constantly using agency. I don't really like it. I like my own staff.'”
critical“Systems in place to check whether staff were safe to work at the service, were not adequate. (Regulation 19 breach)”
incident learning
3 findings
minor“Staff told us the new registered manager had introduced a 'lessons learnt' folder...This was a new process and required further time to become embedded across all supported living schemes.”
moderate“Most of the records we looked at however did not always provide clear information about the lessons that could be learnt from incidents, in order to minimise the risk of a reoccurrence in future.”
critical“The provider had failed to notify CQC, as required, of all incidents affecting the health, safety and welfare of people using the service. This included Court of Protection authorisations.”
consent capacity
3 findings
moderate“one person had paid £115 in taxi fares on four separate occasions...there was no evidence to show they had consented to, or understood the financial impact of, paying for transport costs twice.”
moderate“one person paying for bus fares on several occasions...there was nothing in their file to say that this had been assessed as being in their best interests. The person did not have capacity to understand or manage their finances.”
critical“a relative had been asked to consent on behalf of someone who did not have capacity… This relative did not have these powers so should not have been asked to do this.”
end of life care
3 findings
minor“one person had some very clear instructions in place, whilst another contained gaps relating to more personalised information and preferences, indicating there was more work still to do.”
minor“Information about people's end of life preferences varied across the service. The new area manager told us that by August everyone's end of life wishes would be recorded in their support plans.”
moderate“Information about people's preferences and choices for their end of life care was not evident in the files we looked at. In one file this was completely missing.”
complaints handling
2 findings
minor“felt that responses from the registered manager at times were slow. One relative said, 'Just sometimes I know that if I spoke to staff, they'd pass things on or do things quicker.'”
minor“Some of the information lacked detail, so we could not always be clear what the issues were...There was also limited information about possible actions to mitigate the risk of a future reoccurrence.”
leadership
2 findings
moderate“Many did not know who the registered manager was but felt the general scheme managers did a good job. One relative said, 'The management change so often, there is no continuity in the job role.'”
moderate“due to the instability within the management team since the last inspection we found progress had been made at a slower rate than expected and had also resulted in inconsistencies across the service.”
safeguarding
2 findings
critical“delays in notifying CQC where abuse is suspected or alleged”
critical“we found a small number of concerns that had not been reported to appropriate external organisations, such as the local authority, the Police and CQC, without delay.”
staff competency
1 finding
moderate“At the 2018 inspection we found that required recruitment checks for new staff were not always in place...by this inspection we found some gaps again.”
person centred care
1 finding
moderate“staff supporting another person - who used limited verbal communication, were not aware of such an aid to support this person. Records showed that an external professional had suggested a communication board.”
staff training
1 finding
moderate“some training was now out of date and staff required refresher training… supervision was not always happening on a regular basis”
supervision appraisal
1 finding
minor“a service manager confirmed that the service had fallen behind with staff supervision but there was a plan to address this”