critical“information of concern found during the inspection had not been escalated by staff within the organisation. This meant the registered manager was not aware of the concerns”
medication management
1 finding
critical“a person had been supported to take a medicine prescribed on an as needed basis twice daily which should only have been administered during periods of distress”
governance
1 finding
critical“The provider's governance processes were not effective and had failed to hold staff to account, keep people safe, protect people's rights and provide good quality care”
care planning
1 finding
moderate“People's care and support plans did not always reflect their needs and preferences or promote their wellbeing and enjoyment of life. Information was not person-centred”
staff training
1 finding
moderate“staff had not received training in understanding the needs of people with a learning disability and autistic people, including the use of communication tools and positive behavioural support”
incident learning
1 finding
moderate“The provider had not always managed incidents affecting people's safety well. There was a lack of investigation into possible trends and themes to learn lessons, change practice”
person centred care
1 finding
moderate“The terminology used by staff in people's care plans, daily records and incident reports was not always appropriate or respectful.”
consent capacity
1 finding
moderate“The provider could not evidence how they had considered people's capacity to make decisions...the provider had not recorded any assessments or best interest decisions in their care plans”
supervision appraisal
1 finding
moderate“Where concerns were highlighted regarding staff communication and practice, the provider had not always ensured staff received supervisions in order to support them”
record keeping
1 finding
minor“information was not always detailed and did not accurately reflect investigation outcomes”
complaints handling
1 finding
minor“The provider had a complaints log in place for recording when concerns were raised. However, outcomes and actions were not always clearly documented.”
communication with families
1 finding
minor“some relatives told us they had not received these [surveys]. 'No questionnaire has been sent out for a long time, if ever'”