critical“The provider had not ensured staff fully acted in accordance with the Mental Capacity Act 2005. This was a breach of Regulation 11”
safeguarding
1 finding
critical“Systems in place to look after aspects of people's monies were not always sufficiently robust to protect people from the risk of financial abuse.”
staffing levels
1 finding
moderate“The service aimed to support people with a small and consistent team of staff. However, this was not always possible due to recruitment issues.”
infection control
1 finding
moderate“Within one of the settings visited, areas needed cleaning and refurbishment... Face masks were not always worn... However, risk assessments were not available”
medication management
1 finding
moderate“one person had liquid or dispersible medication but there was no information about the reason for this or any associated risks.”
incident learning
1 finding
moderate“Managers responded to specific incidents or accidents; however, recording around actions taken and oversight to identify any themes or trends was limited.”
governance
1 finding
moderate“the provider's oversight had not identified the issues found during this inspection in relation to compliance with the MCA.”
care planning
1 finding
moderate“some support plans needed to be updated and did not always fully reflect people's goals or aspirations.”
person centred care
1 finding
moderate“Feedback suggested some people were not consistently supported to engage with activities they were interested in, including appropriate sensory stimulation.”
communication with families
1 finding
minor“Relatives views varied in relation to communication with the service. Some felt communication could be improved.”
record keeping
1 finding
moderate“CQC had not been notified about all incidents as required, however these were submitted retrospectively.”
supervision appraisal
1 finding
minor“Staff received support in the form of supervision and appraisals. Systems were being implemented to ensure these were undertaken regularly and consistently”