moderate“We found one recent safeguarding concern that had not been notified to CQC, this was an oversight by the registered manager.”
critical“one of the staff members we spoke with was unable to answer any questions we asked regarding the signs of abuse or what they would do about them in their role as carer”
complaints handling
2 findings
minor“the final outcome was not always recorded in an accessible way, and there was no management oversight of trends.”
minor“Two family members told us they had not felt happy with the outcome of the complaint... the date at which the complaint was resolved was not always recorded”
governance
2 findings
moderate“the spread-sheets had not been updated to reflect this... the quality system was not entirely effective”
moderate“the registered manager and deputy manager were not able at the time of the inspection to provide us with a list of outstanding work”
record keeping
2 findings
minor“care records were not always easy to access as the most recent information was not always the first documents you read and not all care records were accurately indexed”
critical“risk assessments did not include essential information on people's health and how to mitigate risks which meant people were at risk of harm”
incident learning
1 finding
minor“the outcome and learning were not always recorded from events, although the registered manager could tell us of the learning that had taken place.”
end of life care
1 finding
minor“Staff had access to end of life care training but had not completed the training at the time of the inspection.”
medication management
1 finding
moderate“staff had not signed to say medicines had been given, but had put the number of tablets given in the signature box. This meant that you could not always see who had given the medicines”
supervision appraisal
1 finding
minor“when we looked at the team spread-sheet and randomly asked to see supervision records these had not always taken place”
care planning
1 finding
critical“two out of six care plans that had not been updated since 2013...no guidance for staff in the care plan as to what duties to carry out”
staff training
1 finding
critical“three out of 38 staff had been trained in dealing with epilepsy...the action they told us they would take if a person was having a seizure would be considered very unsafe”
staff competency
1 finding
moderate“no training to promote people's knowledge and awareness in working with someone with a learning disability...used language to describe a disability that was outdated and demeaning”
person centred care
1 finding
moderate“inspectors were also not confident that all staff understood how to facilitate meaningful activities with adults with a learning disability”