critical“We have identified a breach in relation to good governance at this inspection.”
moderate“Quality audits had not highlighted required improvements that were noted at the inspection”
critical“there had been no overarching quality assurance audits completed for the service since the last inspection.”
care planning
2 findings
moderate“there was still work to be completed on people's life histories.”
critical“Risk assessments were not always completed. For example... a person at risk of seizures did not have a risk assessment in place.”
staffing levels
2 findings
moderate“people and relatives told us that there was a high turnover of staff and sometimes staffing levels seem low.”
moderate“another member said, 'We never have enough staff, we're always rushed.'”
communication with families
2 findings
minor“some relatives did not always feel that they were asked for their feedback as regularly as they could be.”
moderate“Some professionals shared frustrations with communication and lack of updates from the management team.”
end of life care
1 finding
moderate“Improvement was also required on the completion of end of life care plans for people being supported by the service.”
medication management
1 finding
critical“Recording of medicines was inconsistent... bottles had been opened, however, staff had not dated when this had occurred. This left people at risk of being administered medicine that was out of date”
safeguarding
1 finding
critical“the management team had not made the relevant referrals following safeguarding concerns being reported to them. Retrospective referrals had to be made”
incident learning
1 finding
critical“no audits or reports were being generated from these records to identify trends and patterns... No preventative measures had been put in place”
infection control
1 finding
critical“staff were not following COVID-19 infection control government guidance. On several occasions staff were seen not to wear face masks whilst providing support”
staff training
1 finding
critical“the registered manager confirmed only approximately 50% of the staff had received autism training, however nearly 100% of the people being supported were diagnosed with autism.”
consent capacity
1 finding
critical“People had restrictions in placed on them without evidence of consent given or best interest decision process.”
leadership
1 finding
critical“The general manager and the registered manager confirmed that they had lost oversight of this separate supported living location... This meant there was no overarching management of the service.”
supervision appraisal
1 finding
moderate“The registered manager has never stepped foot in [one of the supported living locations] in the four years I've worked there. I don't know [registered manager] and wouldn't know how to get support.”
record keeping
1 finding
moderate“There was no documentation in the care plan to demonstrate whether their mental capacity had been assessed to consent to that decision”