moderate“At the time of this inspection, the first audit was underway but not yet complete.”
moderate“we could not improve the rating for Well-led on this occasion because to do so requires consistent good practice over time.”
critical“The provider lacked leadership and operational oversight of the agency. The provider had developed an action plan which lacked detail”
medication management
2 findings
minor“Staff had experienced some occasional problems with the new system, but these were decreasing.”
critical“Medicines were not safely managed. National Institute for Clinical Excellence (NICE) guidance was not followed in relation to medicines.”
staffing levels
2 findings
minor“it had been difficult recruiting new staff, particularly during the peak of the COVID-19 pandemic. This had meant existing staff needing to cover sickness and leave between themselves.”
moderate“there was insufficient staff to cover annual leave and sickness... one member of staff was on duty for four weeks”
safeguarding
1 finding
critical“People were at risk of abuse from staff. Other staff failed to report poor practice witnessed by other staff towards people”
consent capacity
1 finding
critical“Mental capacity assessments were not completed for specific decisions. Court of protection orders were not applied for people subject to continuous supervision and restrictions.”
staff training
1 finding
critical“Staff were not attending training that ensure they had the skills needed to deliver personal care to people.”
staff competency
1 finding
critical“The perception of some staff was that people with learning disabilities were to be treated as children and imposed punitive measures for some behaviours.”
leadership
1 finding
moderate“She [provider] doesn't always come back. I have to ask her to respond. I try not to bother... She has left me to get on with it.”
supervision appraisal
1 finding
moderate“One to one supervision to discuss performance, personal development and training needs were not taking place regularly.”
care planning
1 finding
moderate“Care plans were duplicates of the daily routine plans... comments from staff indicated that care plans were not a true reflection of people's current needs.”
person centred care
1 finding
critical“one person was prevented from attending day care services or having treats due to being 'rude'”
record keeping
1 finding
moderate“Daily notes were not always signed or dated by staff... Daily notes were not audited robustly”
incident learning
1 finding
moderate“There was little evidence that there was learning opportunities for staff. Daily notes evidenced that incidents where people challenged the service were not reported.”
other
1 finding
critical“Recruitment procedures followed were not robust and did not ensure the staff employed were suitable to work with adults at risk.”