critical“The provider failed to operate a robust system of governance to comprehensively monitor the quality and safety of the service. This constituted a breach of regulation 17”
critical“The Registered person did not ensure a suitable system was operated to assess, monitor and improve the quality and safety of the service.”
supervision appraisal
2 findings
moderate“appraisals were out of date and there were some gaps in the regularity of staff supervision sessions.”
moderate“gaps in the regularity of 'spot check' visits to people's homes, designed to observe whether care staff properly supported them.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post...the provider has subsequently informed us the manager has resigned and they are recruiting for a new manager.”
critical“there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
record keeping
2 findings
minor“The minutes for some staff supervision sessions did not always demonstrate that action points from the previous meeting were followed through.”
moderate“The daily log sheets were not always satisfactorily completed in relation to how people were supported with food preparation, eating and drinking.”
infection control
1 finding
moderate“the provider could not be assured employees were effectively protecting people from the risk of COVID-19 due to the absence of a robustly organised testing programme.”
consent capacity
1 finding
critical“managerial and supervisory staff did not undertake assessments of people's mental capacity to make decisions when they carried out initial assessments and subsequent reviews”
medication management
1 finding
critical“We found gaps of recording by care staff or inconsistencies in all of the seven MAR charts we looked at.”
care planning
1 finding
critical“The lack of sufficient information and guidance in the risk assessments placed people at risk of avoidable harm.”
safeguarding
1 finding
critical“two people had experienced significant and detrimental risks that were not identified by the provider's own risk assessments”
incident learning
1 finding
moderate“this approach was not implemented in a timely manner following the previous inspection and insufficient progress was demonstrated at this inspection”
staff training
1 finding
moderate“the provider's aim for improving the quality of the training and staff support was still at an early stage and had not been fully implemented”