critical“There was no structured system to review service delivery and ensure high quality care was provided.”
critical“Quality assurance and governance arrangements were not effective to identify shortfalls and promote improvements.”
incident learning
2 findings
moderate“Analysis of themes, trends or patterns were not assessed. Staff were not always informed of the outcome from these incidents.”
moderate“There was not a robust system in place for the provider to evidence how they learned lessons when things go wrong.”
leadership
2 findings
critical“Several staff told us there was a culture within the service where they were not able to speak up for fear of repercussion.”
moderate“The provider recognised the need to recruit an effective and experienced manager to run the service on a day to day basis.”
staff competency
2 findings
minor“The training…well they don't always carry out tasks in the same way. Some carers do things differently than others.”
moderate“Recently employed staff told us there had not been a competency assessment of their practice in certain healthcare tasks before working with people on their own.”
record keeping
2 findings
moderate“The provider told us they carried out regular 'spot checks' of care staff performance but was unable to locate all of these records.”
critical“Record keeping in areas such as care planning and risk assessing was not robust and did not support the consistent delivery of safe and effective care.”
staff training
1 finding
moderate“The provider had not updated their induction training to include the 'Oliver McGowan Mandatory Training on Learning Disability and Autism'.”
communication with families
1 finding
moderate“People shared that they did not always receive their care and support visits from staff they knew. Where changes occurred, these were not always communicated in a timely manner.”
person centred care
1 finding
moderate“One person told us, 'The [registered] manager has never asked me about how I think my care is going.' Another person commented, 'I have never had any forms to fill in.'”
care planning
1 finding
critical“One person's care plan and risk assessment was blank... the person was in receipt of personal care, at risk of pressure ulcers and was diabetic.”
medication management
1 finding
moderate“there were recordings of medicines not being administered but no reasoning why on the MAR chart or in the person's care notes.”
consent capacity
1 finding
moderate“records did not demonstrate that the MCA had been followed... decisions, where a person lacked capacity to consent, were clearly recorded as being in the persons best interests.”
safeguarding
1 finding
moderate“where one person had a deterioration in their skin health, staff took a photograph, but no referral was made to a healthcare professional for review.”