moderate“We saw evidence that medication was not always recorded correctly on Medical Administration Record (MAR) charts.”
moderate“Systems for auditing people's medications were not always clear and robust. Daily counts of medications were on separate sheets, meaning that discrepancies may not have been easy to identify.”
moderate“these protocols did not always contain the relevant information to support the staff in determining if the use of a medication was appropriate.”
staff training
3 findings
moderate“A few staff however had not received updated training to ensure their knowledge was up to date. The training was lacking somehow, the service had promised to train us.”
moderate
“Training was not in place for learning disabilities, in line with the legal requirement introduced in the Health and Care Act 2022 on 01 July 2022.”
moderate“Training records showed that several staff had not completed specialist training relevant to the people they were supporting; for example, diabetes or epilepsy training.”
care planning
3 findings
moderate“Care records did not always contain clear or up to date information for staff on how to support people's needs.”
moderate“care plans did not always contain important information about people's needs or preferences. For example, one person's preference about the gender of staff was not documented.”
moderate“there was a significant disparity in the quality and detail of these documents [PBS plans].”
governance
2 findings
critical“Due to poor governance of the service people were placed at risk of harm. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008.”
moderate“Systems in place had not always identified the issues highlighted by the inspection, such as the concerns regarding medication governance, or the lack of specialist training for learning disabilities.”
leadership
2 findings
moderate“The service is required under the conditions of their registration to have a registered manager. At the time of the inspection there was no registered manager in position.”
moderate“feedback from local partner agencies identified that whilst improvements were being made, the pace of change wasn't always swift.”
record keeping
2 findings
minor“Body maps were not in place to guide staff where to apply prescribed cream or gels to people. Information where to apply the cream or gel was not in the care plan.”
moderate“there was a mixture of electronic and paper records, and systems differed across the supported living services.”
staffing levels
2 findings
moderate“several services were reliant on agency staff to meet people's needs.”
moderate“Some relatives told us that staff shortages meant their loved ones did not always get to engage in as many community activities as they would like.”
infection control
1 finding
critical“We saw some staff were not wearing personal protective equipment (PPE) correctly. For example, we saw a number of staff wearing face masks incorrectly.”
supervision appraisal
1 finding
moderate“Systems in place to monitor staff performance had not identified that spot checks were carried out consistently.”
person centred care
1 finding
moderate“Systems were not in place to ensure people using the service, or their relatives had the opportunity to give feedback on their views of the service they received.”
end of life care
1 finding
minor“The registered manager told us they had not documented people's future wishes for end of life care but this was planned. We will check this at our next inspection.”
consent capacity
1 finding
moderate“Records did not always detail how the MCA or best interests' decisions were incorporated into the service.”
communication with families
1 finding
minor“some family members found communication with the service was not always easy and there was a lack of clarity about who they should contact for information.”
incident learning
1 finding
minor“There were plans in place for the positive behaviour support (PBS) coordinator to review incidents to identify any trends or learning. However, this wasn't always possible whilst the service was awaiting new members of the management team”