critical“Not all MAR provided assurance people received their medicines in line with the prescriber's instructions. PRN medicine protocols were not completed for all 'when required' medicines.”
safeguarding
1 finding
critical“Robust processes and procedures were not in place to protect people from avoidable harm and abuse. Actions taken to robustly investigate these required improvement.”
staff competency
1 finding
critical“An assessment of competence relating to specific topics had not been considered or completed for all staff. For example, bathing practices, tracheostomy, catheter, and stoma care.”
staff training
1 finding
critical“The provider did not ensure all staff employed at the service had received specific training relating to people who were autistic or who had a learning disability.”
supervision appraisal
1 finding
moderate“Supervisions were not undertaken at regular intervals in line with the provider's expectations. Suitable arrangements were not in place to ensure all newly employed staff had received a robust induction.”
governance
1 finding
critical“The quality assurance and governance arrangements in place were not effective in identifying shortfalls in the service. The provider had not identified these failings.”
record keeping
1 finding
moderate“Record keeping arrangements at the service were ineffective. Accessing information during the inspection proved very difficult. Staff were unable to find and share requested documents in a timely manner.”
incident learning
1 finding
moderate“Reporting of incidents, issues and concerns were inconsistent. Statutory notifications to the Care Quality Commission were delayed and not forwarded to us in a timely manner.”
leadership
1 finding
moderate“Their lack of oversight and effective monitoring meant they could not be assured specific tasks delegated to others were happening in line with regulatory requirements.”