critical“The provider did not have robust processes in place to monitor the safety and quality of the service. This demonstrated a continued breach of regulation 17 (Good governance)”
critical“The management oversight of the service needed improvement and audits developed to monitor the quality of care.”
incident learning
2 findings
moderate“There was not a robust system in place for the provider to evidence how they learned lessons when things go wrong and to reduce the risk of reoccurrence.”
moderate“Incidents were not reviewed in a systematic way to reduce the likelihood of a reoccurrence.”
care planning
2 findings
moderate“Care plans and risk assessments had been updated and were accurate, they lacked detail in certain areas and were often generic.”
critical“Risk assessments were not in place and there were no managements plans in place to guide staff on how to reduce the risk of harm.”
leadership
2 findings
critical“The service did not have a manager registered with the Care Quality Commission. The management team were new and had been in post for 6 weeks.”
critical“The provider did not have a manager registered with the Care Quality Commission [CQC]. The previous registered manager left in June 2021 and had not been replaced.”
safeguarding
2 findings
moderate“Not all were confident in the processes for escalating concerns to relevant stakeholders externally.”
moderate“Staff were clear about escalating safeguarding concerns to the management of the service but were not clear about the role of the Local Authority.”
complaints handling
1 finding
minor“The provider's complaints policy and procedure needed updating to ensure information on how complaints were managed was correct to manage people's expectations.”
supervision appraisal
1 finding
minor“There had been slippage with formal supervisions but the management team had identified this and supervisions were planned.”
person centred care
1 finding
moderate“The provider did not have due regard to 'right support, right care right culture', despite being registered as a specialist service for people with a learning disability and autistic people.”
medication management
1 finding
critical“Medicines were not always managed in a safe way. Medicine administration records were not always accurately completed, and there were no medicine profiles or controls for overseeing the arrangements in place.”
staff training
1 finding
moderate“While some training for staff was provided, it was not specific to the needs of the people they supported.”
staff competency
1 finding
moderate“There were no competency assessments to check staff's understanding of what they covered on training or spot checks to review care delivery.”
infection control
1 finding
moderate“The system in place to ensure staff received regular COVID-19 swab testing was not effective and the provider was not able to demonstrate that testing was not being undertaken in line with government recommendations.”
record keeping
1 finding
moderate“There was no record of a formal assessment being undertaken by the agency when care was commissioned with them.”
consent capacity
1 finding
moderate“Staff were not clear whether the person they were supporting had capacity and the documentation was contradictory.”
other
1 finding
moderate“Recruitment processes were not robust and we identified shortfalls in referencing and risk assessments.”