First inspection of newly registered supported living service, rated Requires Improvement overall with one breach of Regulation 11 (consent/MCA). Caring and responsive domains were Good, but governance, MCA compliance, financial safeguarding, staffing consistency and incident oversight required improvement.
Concerns (12)
critical
Consent / capacity
: “The provider had not ensured staff fully acted in accordance with the Mental Capacity Act 2005. This was a breach of Regulation 11”
criticalSafeguarding: “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.”
moderateStaffing levels: “The service aimed to support people with a small and consistent team of staff. However, this was not always possible due to recruitment issues.”
moderateInfection control: “Within one of the settings visited, areas needed cleaning and refurbishment... Face masks were not always worn... However, risk assessments were not available”
moderateMedication management: “one person had liquid or dispersible medication but there was no information about the reason for this or any associated risks.”
moderateIncident learning: “Managers responded to specific incidents or accidents; however, recording around actions taken and oversight to identify any themes or trends was limited.”
moderateGovernance: “the provider's oversight had not identified the issues found during this inspection in relation to compliance with the MCA.”
moderateCare planning: “some support plans needed to be updated and did not always fully reflect people's goals or aspirations.”
moderatePerson-centred care: “Feedback suggested some people were not consistently supported to engage with activities they were interested in, including appropriate sensory stimulation.”
moderateRecord keeping: “CQC had not been notified about all incidents as required, however these were submitted retrospectively.”
minorCommunication with families: “Relatives views varied in relation to communication with the service. Some felt communication could be improved.”
minorSupervision / appraisal: “Staff received support in the form of supervision and appraisals. Systems were being implemented to ensure these were undertaken regularly and consistently”
Strengths
· Staff were kind, compassionate and respected people's privacy and dignity
· Good awareness, skills and understanding of individual communication needs, including Makaton and PECS
· Dedicated Positive Behaviour Support (PBS) coordinator and specialist nurse supporting staff training and development
· Staff supported people to make their own choices and understood their needs and preferences
· Safe recruitment processes including for agency staff
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot 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
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot 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
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving care; Working in partnership with othersNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated