moderate“Care plans had not been completed or reviewed with people's involvement or that of their relatives. Care plans had not been signed by people or their relatives.”
minor“Where the service spent money on behalf of people, records and receipts were kept of this. However, these were not audited or checked by a senior member of staff.”
minor“We did note two criminal records checks out of 40 had not been done for some time and we informed the service of this.”
safeguarding
2 findings
critical“Multiple safeguarding concerns raised by a whistle blower which when assessed by the local authority were substantiated. These included examples of poor care, out of date care plans and risk assessments.”
critical
“Staff shouting at people and leaving them in bed 24 hours...staff handle [person] roughly when putting on their clothes, pulling them around in bed and shouting at them.”
care planning
2 findings
critical“Risk assessments had not been completed in relation to people's health conditions. 5 out of 6 care plans stated a person was either at risk of choking or required modified texture food. There were no risk assessments.”
critical“risk assessments had not been completed in relation to people's health conditions and circumstances...no information on the signs and symptoms of breathing difficulties or high blood pressure.”
governance
2 findings
critical“There had been a lack of quality assurance checks since 2022. MAR chart audits and spot checks had not taken place since 2022.”
critical“Robust systems would need to be put in place to ensure these shortfalls were identified and prompt action taken to ensure people received high quality care at all times.”
person centred care
2 findings
critical“People were supported with personal care at times that suited staff as opposed to when they needed personal care to be delivered...without their agreement, so the day staff would have less work to do.”
minor“One person told us some staff rushed them. We discussed this with the registered manager who said they would investigate the matter.”
staff competency
2 findings
moderate“One staff member we spoke to was unable to tell us what types of abuse to look out for and who to report them to. Another member of staff told us they were unaware of the whistleblowing policy.”
moderate“Some people had cerebral palsy...Some staff we spoke to were not aware of cerebral palsy and the risks that may be associated with this.”
medication management
2 findings
minor“The provider had not regularly assessed staff competency to support people with their medicines.”
critical“staff 'Should pop out medicines and place in pot and to ensure [person] takes medicine in front of carers' ...MARs were not kept of the administration.”
staffing levels
1 finding
critical“Only 2 staff were on duty to support 8 people who lived in a supported living scheme. Six people required the support of 2 staff for personal care and moving safely.”
consent capacity
1 finding
critical“Care plans and risk assessments did not contain information that people had consented to their care and that where they could not give consent, a mental capacity assessment had been carried out.”
leadership
1 finding
critical“There was a high turnover of staff within the management team which lead to inconsistencies in leadership. At the time of the inspection the service did not have a registered manager.”
cultural competency
1 finding
minor“Care records did not also address people's diverse and cultural backgrounds. This meant staff might not have all the necessary information to care for people appropriately.”
communication with families
1 finding
moderate“There were no communication plans or guidance to support staff to understand people's communication and sensory needs. One person had a speech impairment, and another was hard of hearing.”
incident learning
1 finding
moderate“body maps had been completed when people had small bruises or small cuts...this was not being analysed or investigated so action could be taken to minimise any risk of re-occurrence.”