moderate“We identified a shortfall within the recruitment process which limited the providers oversight and opportunity for staff recruitment histories and references to be adequately scrutinised.”
critical“one person's epilepsy protocol stated they needed to be checked on every 30 minutes, however their risk assessment stated the checks were to be completed every 15 minutes.”
moderate“We could not find any records of regular checks for that person. Another risk assessment stated that a different person should be regularly monitored at night. However, the risk assessment did not specify how often.”
care planning
2 findings
critical“one person's epilepsy protocol had not been reviewed since 2016 and contained out-of-date information about the person's medicines.”
critical
“one person's risk assessment clearly stated that staff should check the person's condition at night every 15 minutes. However, according to the care plan, the person was supposed to be checked every 30 minutes.”
governance
2 findings
moderate“Governance processes were not always effective and did not always hold staff accountable, keep people safe, protect people's rights and provide good quality care.”
critical“systems to assess, monitor and mitigate risks to people were not always effective. The registered manager had failed to identify that three people were not receiving safe care at night.”
safeguarding
1 finding
critical“The provider had no effective system in place that could provide staff with information about their responsibilities and where to escalate their safeguarding concerns.”
incident learning
1 finding
moderate“The service did not always manage incidents affecting people's safety well. Staff recognised incidents but did not always report them appropriately.”
staff competency
1 finding
critical“not all staff signed the document to confirm they were familiar with people's care plans... staff did not always follow appropriate guidance when working with the person.”
other
1 finding
moderate“a fire drill was supposed to take place every three months. However, only one fire drill was recorded for 2021 and one fire drill for 2022.”
person centred care
1 finding
minor“one relative of a person told us, 'The only negative is they do not always take [person] out, so by the time he comes home he is climbing the walls to get out'”