critical“The provider had not ensured people's risk assessments were up to date. We found lengthy periods where some had not been reviewed.”
incident learning
1 finding
critical“Staff did not always record incidents. We found examples of incidents which had not been reported.”
staff training
1 finding
critical“The provider had not ensured staff were up to date with mandatory training or ensured competency assessments were completed.”
supervision appraisal
1 finding
moderate
“Supervision was meant to be held every 6 to 8 weeks; this differed across the 4 services and not everyone had received an appraisal.”
governance
1 finding
critical“The provider had not ensured service managers were supported during a lengthy period when there was no registered manager.”
consent capacity
1 finding
moderate“Staff had not ensured MCAs were completed and best interest meetings held for all decisions.”
staff competency
1 finding
moderate“Staff did not always support people as described in their risk assessments. We observed staff give a person food which had not been prepared in line with their SALT assessment.”
person centred care
1 finding
minor“Staff did not always encourage people to do what they could for themselves. They prepared food and did laundry without involving people to promote their independence.”
record keeping
1 finding
moderate“Some actions were overdue and some had been marked as complete where we found the issues remained during our inspection.”