minor“some people were unable to access their written care plan and did not have an accessible format version.”
critical“Records showed one person was at significant risk of malnutrition due to very limited nutritional intake. It was not always clear what action had been taken to monitor and mitigate this risk.”
moderate“Assessment tools to identify risk were not always completed accurately. One person had been assessed as being at 'medium' risk of falls when they should have been assessed as 'high'.”
staff competency
2 findings
minor“One staff member, whose role included fire safety and first aid, did not have all the skills they needed in these areas when we asked about them.”
moderate
“Whilst staff had completed training in the safe handling of medicines, safe practices were not always followed which had resulted in medication incidents.”
person centred care
2 findings
minor“We discussed one person's identified risk of physically responding to others where a few staff told us they did not always feel confident in managing this risk.”
moderate“One relative told us, '[Name] loves to go outside, it is their favourite thing being out in the countryside, but staff don't always enable this to happen.'”
medication management
2 findings
critical“Medicine stock discrepancies we found during our inspection meant we could not be assured people had always received their medicines as prescribed.”
critical“Stock discrepancies were found in one persons' controlled medicine.”
governance
2 findings
critical“Medication checks and audits had not identified the issues we found which meant actions had not been taken to ensure people always received their medicines as prescribed.”
moderate“Supported living shared home checks and audits were mostly delegated by the registered manager to field care staff...effective monitoring of the quality of the services did not always take place.”
safeguarding
1 finding
critical“In one shared home, all bedrooms were locked by staff and the kitchen had restricted access and cupboards were locked...we found no appropriate legal authority in people's plans of care.”
staff training
1 finding
moderate“Two staff members felt they needed training around learning disabilities, autism and managing specific behaviours.”
consent capacity
1 finding
critical“We found some instances where restrictions were in place and people were being deprived of their liberty without the appropriate legal authority.”
incident learning
1 finding
moderate“The effectiveness of training and spot checks had not always been explored to determine if improvements were needed.”
infection control
1 finding
minor“Some staff were seen wearing their facemasks under their nose or chin.”
record keeping
1 finding
moderate“Care records, such as 'hospital passports', containing important emergency information were not always accurate or up to date.”
leadership
1 finding
moderate“Some relatives felt there was a lack of 'management presence' in some services and the lack of effective role modelling to staff impacted the quality of care.”