moderate“People were supported by a high percentage of agency workers at the time of our inspection due to ongoing recruitment and staffing issues.”
staff training
1 finding
critical“Person centred inductions were not always carried out with new agency staff. Agency staff were not always provided with adequate time to get to know people.”
incident learning
1 finding
critical“Records of incidents and accidents were not effective, and any outcomes or lessons learnt from them were not always recorded or shared with staff and the appropriate bodies.”
medication management
1 finding
critical“Guidance and records were not always in place to support the safe administration of topical medicines... some records were missing.”
record keeping
1 finding
moderate“Some records kept in people's bungalows used by staff to communicate with each other were not appropriate or fit for purpose and were not monitored by the manager.”
governance
1 finding
moderate“Audits were carried out by the manager. However, these did not always identify and address issues effectively.”
person centred care
1 finding
moderate“The culture at the service did not always support person centred practices. The service was managed and viewed as 'a whole' rather than individual tenants in their own homes.”
care planning
1 finding
moderate“People's positive behaviour support plans were not always being followed and records of incidents did not include any evidence of them being followed.”
communication with families
1 finding
minor“Relatives...felt they and their relatives that use the service had not been asked for their feedback on the service or given an opportunity to attend any engagement meetings.”