critical“Risks were not always fully assessed to ensure people and staff were kept safe from harm. This included some risks associated with behaviours which had resulted in injuries to people.”
staffing levels
1 finding
critical“Staff who had transferred into the service did not have completed references and a Disclosure and Barring Service (DBS) check in place before they started work.”
governance
1 finding
critical“Systems to monitor the quality and safety of the service did not ensure all aspects of the service were checked to drive improvement.”
incident learning
1 finding
moderate“During our last inspection it was identified that recruitment records were not sufficiently robust. This continued to be the case. Lessons had not been learnt.”
safeguarding
1 finding
moderate“There was a system to support the service in managing abuse to safeguard people but there was no central record of safeguarding concerns.”
record keeping
1 finding
moderate“Daily records staff completed did not reflect the times staff arrived or times when specific care was provided to people to demonstrate this was in accordance with expectations.”
other
1 finding
critical“Statutory notifications had not been sent to us as required. This is information about important events such as police contact which the provider is required to send to us by law.”
consent capacity
1 finding
minor“Some staff were not clear in their knowledge of the MCA despite having completed training.”