Mencap Yeovil Support Service improved its Safe rating from Requires Improvement to Good, demonstrating safe recruitment, effective safeguarding practices and positive person-centred outcomes for people with learning disabilities. However, Well-Led remained Requires Improvement due to governance gaps including the absence of a registered manager, inconsistent care plan auditing, and agency staff lacking timely access to training records and electronic care planning systems.
Concerns (7)
criticalCare planning: “1 person had no risk assessment in place for staff to follow relating to their epilepsy and diabetes.”
moderateRecord keeping: “audits had not always identified missing information within care plans despite being reviewed recently.”
moderate
Staff training
: “agency staff did not have the necessary training to support the people using the service.”
moderateGovernance: “agency staff did not have access to this information. Agency staff only had access to people's paper care plans however the quality of the information available for agency staff varied.”
moderateIncident learning: “There had been some under reporting of accident and incidents at the service.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post.”
minorPerson-centred care: “The service held regular meetings with people to ask them their views on their support. However, these were not always recorded formally.”
Strengths
· People and relatives reported feeling safe and expressed high satisfaction with the support received.
· Safe recruitment processes in place including DBS checks and employer references.
· Staff received safeguarding training and knew how to recognise and report abuse.
· Medicines managed safely with relevant staff training and competency spot checks.
· Infection control systems, PPE usage and hand hygiene practices were in place.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated