critical“People were not protected from unnecessary control and restraint. There was a breach of regulation 13 (Safeguarding service users from abuse and improper treatment)”
staffing levels
1 finding
critical“There were not always sufficient staff deployed to ensure people's assessed needs were met. There was a breach of regulation 18 (Staffing)”
staff training
1 finding
critical“Most staff had not undertaken specialised communication training after a short session on their induction.”
governance
1 finding
critical“Systems to monitor the quality and safety of people's support were not effective. There was a breach of regulation 17 (Good Governance)”
incident learning
1 finding
moderate“Investigations into incidents and accidents did not always involve robust analysis of the root cause. This meant actions taken were not always sufficient.”
care planning
1 finding
moderate“Risk management strategies in place to support people when they were distressed were not always applied consistently.”
consent capacity
1 finding
moderate“Oversight of DoLS within the service had not been robust and the status of applications was not known within the senior team.”
record keeping
1 finding
moderate“Complete and accurate records in respect of people's care and support had not been maintained.”
staff competency
1 finding
moderate“Risks associated with the support people needed to move safely had been assessed, however the competency of staff undertaking this support had not been reviewed after their initial training.”
supervision appraisal
1 finding
minor“Staff told us they had experienced mixed support. We heard reflections on changes at manager level leaving staff uncertain about their support.”