minor“one person's cream was not stored in the medicine cupboard and did not have an expiry date on it. In addition, there was no body map to show where the cream should be applied.”
minor“There were no easily accessible protocols for staff about when and how to administer 'as required (PRN)' medicines...agency staff would be unable to understand when the person needed pain relief.”
care planning
2 findings
moderate“Some risk assessments and care plans needed review. For example, to ensure they were up to date, accurate or included enough information for staff to support people safely.”
critical“A member of staff told us, "There was not a lot of information about [Name]. A lot of it wasn't accurate."”
consent capacity
2 findings
minor“There had been delay in carrying out assessments of some people's mental capacity, but this had been addressed and decisions were recorded in line with legislation.”
critical“There were restrictive practices in place such as locked doors, locked cupboards and one to one support. The lack of any capacity assessments or best interest decisions meant the provider could not be sure that care was being delivered lawfully.”
communication with families
2 findings
moderate“One professional said, 'I have concerns around the lack of communication [from managers] with the other agencies involved in my client's care'. Another added, 'I need to hear more from them'.”
critical“The provider had not acted on duty of candour. People's relatives had not been informed of the safeguarding concerns.”
staffing levels
2 findings
minor“One of the supported living homes was fully staffed, but others had vacancies. There had been significant staffing changes within the past six months.”
critical“Staff were unable to provide the assessed staffing needs to others living at the service...there were insufficient staff deployed at the service.”
safeguarding
1 finding
critical“People were not protected from assault by others and staff described how people had become distressed and frightened.”
governance
1 finding
critical“The provider had failed to operate an effective system to monitor the quality of the service.”
staff competency
1 finding
critical“One person had complex needs and could display behaviours which challenge. Staff received no specific training...Staff told us, "Our training was not sufficient to support them."”
infection control
1 finding
critical“There was no risk assessment in place to identify and mitigate this risk...We observed a shared hand towel in the communal toilet downstairs at the service.”
incident learning
1 finding
moderate“The provider failed to learn from incidents and put measures in place to prevent the risk of recurrence...Staff knew how to report incidents but told us they did not receive feedback.”
person centred care
1 finding
critical“Significant changes at the service had a negative on people's safety and well-being. Their needs and choices had not been considered.”
record keeping
1 finding
moderate“Systems had not been operated to ensure the accuracy and effectiveness of care records...Shortfalls in care plans and risk assessments had not been identified.”