critical“People did not consistently feel safe in their homes... people also told us they did not feel safe with some of the staff that supported them.”
staffing levels
1 finding
critical“People across all settings repeatedly told us there were not enough staff to meet their needs... waiting for your care. Sometimes I go to bed much later than I would like to.”
medication management
1 finding
critical“One person had been prescribed eardrops for 7 days, but staff continued to administer it for 11 days.”
governance
1 finding
critical“The provider had failed to establish systems and processes that appropriately assessed, monitored and improved the quality and safety of people's care.”
person centred care
1 finding
critical“People did not consistently receive care that was person-centred... they had to prioritise the needs of the group, rather than the individual.”
staff competency
1 finding
moderate“Some of the settings relied on high levels of temporary staff who did not always have the skills and experience to meet people's needs and expectations.”
complaints handling
1 finding
moderate“At one setting in particular, people said they had given up raising complaints because nothing was ever done.”
staff training
1 finding
moderate“Staff turnover was so high... this learning had not always been successfully embedded.”
care planning
1 finding
moderate“The assessment process had not been used effectively to ensure services were only offered where people's needs could be fully met.”
incident learning
1 finding
moderate“Multiple management changes, alongside staffing shortages had meant that a culture of learning from events had not yet been established.”
supervision appraisal
1 finding
minor“I'm currently taking the time to do their supervisions and appraisals so I can show them the standards that are expected.”