moderate“At the time of our inspection there was not a registered manager in post.”
critical“Systems and processes to see the effective running of the service were inadequate. This placed people at risk of harm.”
leadership
2 findings
minor“Staff acknowledged that changes in management over time had created some inconsistencies but were happy they were being supported well by line managers that were in place.”
critical“The registered manager and provider had not promoted an open and supportive culture... There were signs of a closed culture in which staff were raising concerns and not feeling listened to.”
safeguarding
1 finding
critical“Not all staff were up to date with safeguarding training or knew what to do if they had any safeguarding concerns.”
medication management
1 finding
critical“The storage, administration and recording of medicines was not always safe. We found a range of issues which included medicine administration records (MAR) not being completed in line with best practice and containing unexplained gaps.”
person centred care
1 finding
critical“People did not always receive person-centred care which was appropriate, met their needs and reflected their preferences. This was a breach of regulation 9(1).”
care planning
1 finding
critical“Care and support plans were in the process of being updated by the interim management team but had not contained up to date, accurate or relevant information for a long time.”
complaints handling
1 finding
critical“Complaints were not acknowledged, investigated and acted upon in a timely manner. This was a breach of regulation 16(1).”
incident learning
1 finding
critical“There was no system in place to learn lessons when things went wrong. Regular analysis of incidents, accidents and people's expressive emotions did not happen.”
staff training
1 finding
moderate“Some people used Makaton sign language but staff had not received training in this area.”
supervision appraisal
1 finding
moderate“Staff supervision and team meetings did not take place regularly so staff were not given opportunities to receive key updates, share information and discuss their development.”
staffing levels
1 finding
moderate“Some staff had left recently and the remaining staff team were stretched to ensure sufficient staffing levels were maintained.”
communication with families
1 finding
moderate“Those who had submitted responses had not received any feedback on the results. One relative said, 'I had one, but I didn't fill it in as what's the point.'”
record keeping
1 finding
moderate“Records were disorganised. Staff told us they did not have confidence the registered manager took appropriate action when incidents occurred.”
infection control
1 finding
minor“We identified one of the cleaning products were not suitable or effective against COVID-19... Cleaning schedules were not always signed to show tasks completed.”
end of life care
1 finding
minor“The provider had an end of life policy but people and those important to them had not been offered opportunities to share their views as part of end of life care planning.”