critical“the provider and staff told us they locked 1 person in their home and records showed this had been happening for at least 4 months”
medication management
1 finding
critical“1 person was prescribed a PRN topical steroid cream. However, MARs showed staff had applied the cream every day for at least 7 months.”
care planning
1 finding
critical“When risk assessments were completed, they did not contain enough information to inform staff how to support people safely.”
governance
1 finding
critical“The provider did not have an effective governance system or robust quality assurance processes. Quality assurance audits were not completed.”
incident learning
1 finding
critical“The provider did not complete effective investigations into accidents and incidents and had no system to identify or monitor patterns and trends.”
consent capacity
1 finding
critical“the provider told us they did not complete mental capacity assessments or follow best interest decision making processes”
record keeping
1 finding
moderate“1 person's logbook for the period between 20 October 2022 and 8 February 2023 was returned to the office on 23 February 2023 and only 5 days were checked.”
staff training
1 finding
moderate“Staff did not receive training in specific conditions, for example, diabetes and catheter care.”
complaints handling
1 finding
moderate“The registered manager sent an outcome letter to the complainant during the inspection, which was dismissive of their experiences and did not reflect good practice.”
staff competency
1 finding
critical“records showed staff who were not clinically qualified provided clinical advice without consulting health professionals”
leadership
1 finding
critical“The registered manager did not demonstrate an understanding of the regulatory requirements or relevant legislation. For example, they asked when the Mental Capacity Act (2005) had been introduced.”
supervision appraisal
1 finding
minor“We found staff supervision records picked up areas for improvement but did not see evidence of action taken in response.”