critical“The MAR for one person showed staff had signed for supporting them to take their medicines five times across 20 days when care records showed the person was visiting family.”
moderate“their medicine profile did not have a guidance sheet for circumstances on when and how much of the medicine to offer...it was not administered as prescribed.”
record keeping
2 findings
critical“One incident report stated the person was 'taken to room' and 'contained.' Their daily record stated 'physical restraint' was used...the incident summary stated the person was 'prompted' and 'invited'.”
minor“in one case the reviews were four months out of date.”
complaints handling
2 findings
moderate“It took over two months before a further response to the complaint was received...the explanation meant the response would still have taken 50 days.”
minor“at the time of the inspection, the complaint was six weeks old without being resolved.”
consent capacity
2 findings
critical“People's care records did not include assessment of their capacity to consent to receiving care and support from the service.”
critical“applications to the Court of Protection, as required for people in supported living schemes, had not yet occurred.”
staff competency
1 finding
moderate“One staff member told us they had started giving medicines to people through on-site support and checks, but not yet completed online training.”
governance
1 finding
critical“Quality and risk audits were not consistently effective as they had not identified the concerns and service shortfalls that we found.”
incident learning
1 finding
critical“Three police incidents and a safeguarding matter were not notified to us, as required by legislation, until we pointed this out to the management team.”
safeguarding
1 finding
critical“The service relied too much on our interventions to support continuous learning and improvement...a safeguarding matter were not notified to us, as required by legislation.”
staff training
1 finding
minor“The induction process was not in line with the national Care Certificate which is seen as best practice for ensuring each new staff member has demonstrated sufficient knowledge.”