critical“The service did not always provide enough staff that had the right mix of skills, competence or experience to support people to stay safe and meet their needs.”
staff training
1 finding
critical“Staff had not completed the provider's 'Autism and eating disorders across the lifespan' or the 'Oliver McGowan learning disability and autism training'.”
supervision appraisal
1 finding
critical“The provider's supervision and appraisal schedule had not been completed for 2023...no other supervisions appeared to have been completed since 2019.”
governance
1 finding
critical“The registered manager had failed to consistently assess, monitor and improve the quality of the service and to effectively operate systems and processes to ensure compliance.”
complaints handling
1 finding
critical“The failure to investigate and take necessary and proportionate action in response to complaints was a breach of regulation 16(1) Health and Social Care Act 2008.”
staff competency
1 finding
critical“One senior staff member had been appointed without evidence of a Disclosure and Barring Service (DBS)...no evidence to demonstrate the staff member had a current DBS had been provided.”
person centred care
1 finding
moderate“People were not always enabled to make choices for themselves by the provider...agency staff did not always understand how they wished their privacy and dignity maintained.”
leadership
1 finding
moderate“Most staff told us they did not feel valued and the service experienced poor leadership, which created a negative culture within the service.”
incident learning
1 finding
moderate“Accident, incident, and behavioural incident reports did not always record whether analysis of the circumstances had been completed.”
record keeping
1 finding
moderate“The updated schedule did not show the training records for the registered manager and two team leaders.”