moderate“investigations were not always fully completed or analysed. This meant opportunities were missed to make improvements to the quality of care and did not mitigate future risks to people.”
moderate“Action plans created following investigations were not being followed.”
governance
2 findings
moderate“accidents and incidents were not always reviewed by the registered manager and actions not recorded. This meant the registered manager could miss opportunities for improvement.”
critical“Audits were not in place to drive forward improvements. Governance systems identified by the registered manager had yet to be implemented.”
supervision appraisal
2 findings
moderate“Staff were not supervised in line with the organisations own policy on frequency of supervision...some staff had longer gaps in supervisions prior to the pandemic.”
minor“they had raised an unofficial concern...they felt staff sometimes needed more direction and supervision, to ensure people were supported to be as independent as possible”
safeguarding
1 finding
critical“Not all allegations of abuse made to the provider had been investigated or referred to the local authority safeguarding team.”
medication management
1 finding
critical“Checks in relation to when medicines were opened or expired were not in place. Expired medication was found.”
care planning
1 finding
critical“Risk assessments and care plans lacked detail and guidance for staff to respond to risk effectively.”
staff training
1 finding
critical“Some staff were supporting people with complex needs with minimal training and induction.”
record keeping
1 finding
critical“A significant amount of records were not current or well maintained...Some records were not in place at all, including performance development plans, supervisions, appraisals.”
leadership
1 finding
moderate“Not enough action had been taken to address the poor culture in two of the 'support living' settings.”
person centred care
1 finding
minor“Some people's choices were not always respected by staff.”