moderate“some risks identified had not been fully assessed to guide staff on how it can affect people. Fire risk assessments did not always include information regarding the support people required.”
moderate“one persons' risk assessment did not contain clear guidance for staff to support them to mobilise safely.”
moderate“care plans and found these did not contain any preadmission assessments”
medication management
3 findings
minor“there wasn't a protocol in place to indicate the dose and what the 'as required' medicines should be given for, to the person.”
critical
“MAR for one person showed they were being administered PRN pain relief. However, this was not detailed on the list of prescribed medicines on the person's MAR.”
critical“no clear indication of what medicine, dose, route and frequency the medicines should be administered and in what circumstance. This placed people at risk of potential overdose.”
staff training
2 findings
minor“the registered manager told us they were in the process of arranging the recently introduced mandatory training for staff working with people with a learning disability and people with autism.”
moderate“registered manager told us they could not access any records in relation to staff training as the subcontracted external agency that held records were unable to provide”
consent capacity
1 finding
moderate“not all staff knew what the MCA was in relation to but provided us with examples of how they sought people's consent and supported them in the decision-making process.”
governance
1 finding
critical“registered manager who told us they had not undertaken any audits of the service. We were not assured that quality assurance systems were effective”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
record keeping
1 finding
critical“Records were not easily accessible nor always in place for us to review. For example, there were no supervisions records, staff induction records”
supervision appraisal
1 finding
moderate“no records of staff supervision or induction. The registered manager told us staff did not have formal supervisions.”
person centred care
1 finding
moderate“care records clearly identified people's clinical needs, however made no mention of people's preferences in relation to the care and support they received and lacked personalisation.”
communication with families
1 finding
moderate“People's communication needs and guidance for staff were not always robustly recorded in their care plans.”
incident learning
1 finding
moderate“People did not always receive care from a service that learned lessons when things went wrong... provider had identified some of the issues found during this inspection however failed to act in a timely manner.”
other
1 finding
moderate“registered manager failed to ensure robust pre-employment checks were undertaken prior to staff working at the service.”
missed or late visits
1 finding
moderate“we were not assured the registered manager monitored staff arrival and departure times. This meant we were not confident people received care and support on time”