critical“3 separate incidents had occurred which would be considered as requiring safeguarding referrals...the provider had not recognised these incidents as potential safeguarding incidents”
incident learning
1 finding
critical“incident/accident forms were not completed in full identifying the cause for the incident, immediate actions taken and what lessons had been learned”
care planning
1 finding
critical“one person regularly became physically aggressive causing harm to themselves, staff and others. There was limited information about how staff could support the person and no strategies”
staff training
1 finding
critical“staff had not received training to understand how to support the person in the event they had a seizure...learning disabilities and autism. This training had not taken place.”
supervision appraisal
1 finding
moderate“Staff were not always given the supervision where they needed to discuss their work and to ensure they had the knowledge and skills to care for people safely.”
consent capacity
1 finding
moderate“Mental capacity assessments had not been undertaken...The provider had not completed best interest decisions in relation to the care they were providing”
governance
1 finding
critical“monitoring systems...did not always indicate where there were gaps in the training provided...incidents and safeguarding concerns were not always reported to the local authority and CQC”
person centred care
1 finding
moderate“People's care plans did not always provide staff with information on how to support the person to meet their specific needs when they became upset or frustrated.”