moderate“Staff in one accommodation told us they did not know who was subject to a Deprivation of their Liberty in the community and there was no paperwork within the care files.”
minor“We had not always been informed of full information about some incidents, which was discussed with the registered managers to address in future notifications to us.”
minor“some staff supervision records and other office documentation were also held within people's home; this was discussed with the registered manager and these files were to be moved”
medication management
2 findings
critical“Handwritten medication administration records (MARs) were not signed by 2 members of staff to ensure they had been transcribed correctly.”
critical
“One person was prescribed a fortnightly injection, which was administered by staff who had not completed formal training or had their competencies assessed.”
consent capacity
2 findings
critical“Assessments of people's capacity to make specific decisions, for example finances or medicines, had not always been completed and best interest meetings had not been arranged.”
minor“documentation for the mental capacity assessments and best interest meetings were held with social workers but they told us they would contact them for copies for people's care files”
care planning
2 findings
moderate“People's care treatment and support plans did not always reflect their range of needs.”
minor“there were some aspects of the care plans which could be more comprehensive in detailing the action staff were to take to support people, for example in managing behaviours which could be challenging”
staffing levels
1 finding
critical“Visits could not take place at night in 1 person's accommodation due to a shortage of staff. There was only 1 member of staff on duty on a night shift.”
governance
1 finding
critical“The management team had failed to identify the concerns and shortfalls found at this inspection.”
incident learning
1 finding
moderate“Accident and incidents were reviewed by the registered manager, however there was not always evidence that lessons had been learned.”
safeguarding
1 finding
moderate“Staff were not always aware of safeguarding concerns that had been submitted and did not receive any feedback.”
supervision appraisal
1 finding
moderate“Staff supervision and support systems were not consistent and did not meet their needs.”
staff training
1 finding
moderate“Staff had not received appropriate training to prevent, de-escalate and manage challenging situations.”
person centred care
1 finding
moderate“The provider did not ensure people and their relatives were involved in decisions about their care and restrictions were placed on people without their involvement.”
leadership
1 finding
moderate“Staff did not always feel able to raise concerns and did not feel valued by senior managers. 'If we raise anything they [senior managers] shut you down'.”