critical“Restrictions on people's care and support were not always appropriate or monitored clearly. There was a lack of oversight on the use of restriction at times.”
critical“Systems to protect people from the risk of harm had not been consistently followed and staff concerns had not been promptly acted upon. This was a breach of regulation 13.”
governance
2 findings
critical“The lack of consistent management oversight and robust governance placed people at the risk of harm and meant they did not always receive, quality, effective, person-centred care.”
critical“The lack of consistent management oversight and robust governance placed people at the risk of harm. This was a breach of regulation 17 (Good governance).”
care planning
2 findings
moderate“Daily records relating to the delivery of care and support were at times incomplete or missing. The provider agreed to review this.”
critical“Risk assessments did not always hold sufficient information to guide staff on action to take to mitigate risk.”
consent capacity
2 findings
critical“Mental capacity assessments, best interests' decisions and DoLS applications did not always contain all of the required information.”
critical“People within one supported living service did not have appropriate decision-making processes in place. Restrictions did not have the required legal authorisations in place.”
record keeping
2 findings
moderate“Records relating to what food and fluids people had consumed were at times incomplete or missing, meaning it was unclear if their needs had been met on certain days.”
moderate“Care plan reviews had documentation in place, however, did not always evidence the involvement of people, relatives and health care professionals.”
staff training
2 findings
moderate“On occasion some staff members training was out of date and needed to be refreshed. At times, staff training was out of date, and this had not been rectified by the management team.”
moderate“Staff training records across all the services showed that not all staff were up to date with their essential training. The provider had identified this through audits but had failed to take action.”
supervision appraisal
2 findings
moderate“Staff received supervision from management to ensure they could learn and develop within their role. However, on occasion these were completed infrequently.”
moderate“Staff supervision was not consistently evidenced across all services. Staff at one service told us they felt unsupported and not listened to by senior managers.”
incident learning
2 findings
moderate“Accidents and incidents were not always analysed to identify key trends which could help prevent them from occurring again.”
moderate“Incidents in one service although fully recorded by staff had not been promptly reviewed and analysed. This meant lessons learned had not been identified.”
communication with families
2 findings
minor“Some relatives told us they would like to receive more updates from the management team regarding their loved ones. The provider agreed to look into this.”
minor“Two services had not promptly responded to concerns raised by relatives. Relatives told us the provider contacted them for their views but said they hadn't been asked for feedback recently.”
staffing levels
1 finding
moderate“There were not always enough staff to support people. At one location, we were unable to determine if a person received 2:1 support to access the community in line with their assessed needs.”
person centred care
1 finding
moderate“People's care and support plans did not always focus on positive outcomes or goals to aim for which could improve their quality of life.”
end of life care
1 finding
moderate“There was an example of a person in receipt of palliative care who did not have a plan in place or any evidence to suggest a discussion had been held.”
leadership
1 finding
moderate“There was a registered manager in post at the beginning of the inspection. However, they left before the report was published.”