First inspection of a small supported living service rated Requires Improvement overall, with three regulatory breaches identified around risk assessment, recruitment and governance. Care was found to be effective and caring, but care planning lacked person-centred detail and audits failed to identify safety issues including fire testing, medicines competency and COVID-19 oversight.
Concerns (7)
critical
Governance
: “Audits failed to pick up the lack of appropriate risk assessments around people's personal risks... breach of regulation 17”
criticalOther: “Systems had not been established to ensure safe recruitment. This placed people at risk of harm. This was a breach of regulation 19”
criticalSafeguarding: “People's known risks were not adequately assessed. This included a significant risk around a person's mental health... lack of guidance for staff”
criticalOther: “There were irregular tests of fire alarm systems to ensure systems were working properly. At the time of the inspection, there was no fire risk assessment in place.”
moderateCare planning: “Care plans were not person centred. There was information on what people needed but no information to explain to staff how could support people to achieve that goal.”
moderateStaff competency: “there were no records of staff competency following medicines training to ensure staff understood how to safely administer medicines”
moderateRecord keeping: “Application forms were not always fully completed. There were gaps in applicant's employment and education history with no documentation”
Strengths
· Staff had been trained in safeguarding and were able to explain how to keep people safe from abuse
· Comprehensive induction with Care Certificate completion and shadowing of experienced staff
· Regular supervision and supportive registered manager
· Positive feedback from relatives about kind and caring staff attitude
· Strong infection control practices with appropriate PPE use and staff training
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
effective: Assessing people's needs and choicesNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare servicesNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and controlNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Duty of candour, continuous learning and working in partnership with othersNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated