minor“a couple of care plans and risk assessments were reviewed, which lacked the details identified by the provider's audit”
moderate“staff handover documents used to share information with staff about people's care and support needs were poorly completed. Information was limited impacting on staff ability”
care planning
2 findings
minor“Risk management procedures were not always effective. Some people's support plans and risk assessments were reviewed and amendments made.”
moderate“People's support plans and risk assessments were not always reviewed and amended in a timely manner following incidents.”
safeguarding
2 findings
critical“There's bullying from other people, I've been hit, spat at, I feel frightened, I've threatened to self-harm, I sometimes call the police and have hit back too”
critical“The failure to ensure people were protected from abuse and having effective systems and processes to manage actual and allegations of abuse, put people at risk of harm.”
staffing levels
1 finding
critical“Staff deployment in two supported living settings were identified as being unsafe, due to people's dependency and support needs. This had a negative impact on people's safety.”
staff competency
1 finding
critical“staff feedback confirmed they did not feel sufficiently skilled or confident in some aspects of care. This included concerns in managing challenging behaviour and meeting associated mental health care”
staff training
1 finding
critical“The failure to ensure staff deployment met people's individual care needs and safety, and staff were trained and supported effectively compromised people's safety.”
incident learning
1 finding
critical“there was a lack learning to understand and manage incidents effectively and a lack of action post incident to support people's well-being.”
governance
1 finding
critical“the shortfalls in the fundamental care standards found during this inspection, had not been identified by the provider's internal checks.”
leadership
1 finding
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
medication management
1 finding
moderate“people's medicine support plan, risk assessment and other additional care records were not fully detailed or consistent. This was confusing for staff”
communication with families
1 finding
moderate“I have asked for a meeting with the manager, I have phoned and left messages, but they never got back to me.”
person centred care
1 finding
moderate“Improvements were required to ensure people were consistently supported to be involved in their care and support that maximised their choice, control and independence.”