critical“Medicine errors would be a concern. This has been raised a couple of times. There should be no reason why people are running out of meds and at times this happens.”
critical“Only 17% of staff were trained to administer emergency intervention medicines.”
critical“medicines were not always stored at the correct temperatures. Records of temperature monitoring was inconsistent and in one bungalow the intervention medicines were being stored in a room with a temperature reading of 30⁰C.”
moderate“There were no records of why certain 'when required' (PRN) medicines had been administered or if they had been effective.”
critical“Only 26% of staff were trained to administer emergency intervention medicines and 25% of staff to administer medicines.”
critical
“documents to help staff to administer when required 'PRN' medicines were not in place for all prescribed medicines.”
care planning
3 findings
critical“People's risk assessments were not clear or coordinated with the information stated in the care plans...someone had been identified with a choking risk, this was not clear in the care plan or risk assessment.”
critical“People's risk assessments were not always clear or coordinated with the information stated in the care plans. There were examples where risks had been identified but risk management strategies were not clear.”
moderate“People's risk assessments were not clear or coordinated with the information stated in the care plans.”
person centred care
3 findings
critical“The service provided 'blanket rules' which resulted in inappropriately restricting people's choice and control. For example, the service locked bathroom doors so they could not be accessed freely.”
minor“Staff using language that was not always respectful or encouraged equality. For example, people being 'Non-compliant' and 'Staff toilets'.”
moderate“Care and support plans failed to reflect people's aspirations and future goals or focus on people's quality of life outcomes.”
governance
3 findings
critical“The provider and registered manager did not have a robust quality assurance system in place...the management team did not have clear oversight that these were actioned.”
critical“actions following the audits were not always captured in a service improvement plan, which meant the management team did not have clear oversight that these actions were being completed.”
critical“provider had shown an inability to effectively and in a timely way address the concerns raised at the previous inspection.”
consent capacity
3 findings
moderate“We found example of where staff did not look at the least restrictive practice. There was a lack of consideration in protecting and promoting people's rights.”
moderate“Where people lacked capacity to make a decision, we found not all decisions were documented in a way that assured us that the person's voice was heard.”
moderate“Staff were not always able to explain why there were decisions to restrict people or if this was the least restrictive measure to take.”
safeguarding
2 findings
critical“Where safeguarding's were identified, these were not always sufficiently prioritised...suggested improvements had not been embedded. This meant that people continued to be at risk.”
critical“Staff were not always confident on what to look out for or recognise where people were put at risk of abuse.”
staffing levels
2 findings
critical“Due to staff changes a staff member was on their own...a person put their hand on the hob of the oven. This person's risk assessment indicated they should have one to one support.”
critical“there had been times where staffing levels were critically low which put people at risk... people had not received their commissioned hours.”
staff training
2 findings
moderate“People did not always receive support from staff who had the relevant training, including around learning disability, autism, mental health needs and human rights.”
critical“only 24% of staff had received this [first aid training]. Only 25% of staff were medicine trained.”
incident learning
2 findings
moderate“There was a lack of shared lessons learnt with the whole team...the registered manager gathered information relating to accident and incidents, however, did not effectively look at the overall trends and themes.”
critical“There was a lack of shared lessons learnt with the whole team... the manager did not effectively look at the overall trends and themes.”
communication with families
2 findings
moderate“There is a serious problem with management. They don't communicate and they are short staffed.”
minor“One relative said, 'They are lovely people, but they just keep changing - we don't know what they are doing.'”
record keeping
2 findings
moderate“People's care records were not always updated in a timely manner when changes were made by healthcare professionals.”
moderate“Records were sometimes being completed by staff not employed by the provider.”
leadership
2 findings
moderate“The management team had not recognised support practices did not promote person-centred, open and empowering care...We found staff using parts of people's kitchens for their own property.”
moderate“At the time of our inspection there was not a registered manager in post.”
supervision appraisal
1 finding
moderate“Staff supervision records were not consistent, and staff felt there needed to be more team meetings. I have not been asked once in the last 6 months how are you doing by my bungalow manager.”
infection control
1 finding
moderate“We observed staff not following government guidance when using personal protective equipment (PPE)...staff were deployed across all of the supported living services and did not cohort staff teams.”
cultural competency
1 finding
moderate“Staff used language that was not respectful or age appropriate for example, using language such as 'good boy' and being 'non-compliant.'”