critical“systems were either not in place or robust enough to assess, monitor and mitigate risks within the service. This was a breach of regulation 17 (Good governance)”
minor“there was no documented minutes of these meetings and we discussed this with the manager. He confirmed that such meetings would be documented in future.”
minor“Each audit identified areas of concern and issues, however, the service did not always list the actions taken to remedy the concern or issues.”
medication management
2 findings
moderate“guidance was generic and did not provide specific instructions. For 1 person who was prescribed an anticoagulant, no information was available around possible side effects”
moderate
“discrepancies in the way staff from different supported living settings carried out medicines audits...lack of uniformity around quality assurance systems for medicines management”
safeguarding
1 finding
critical“a number of safeguarding concerns, which were being or had been investigated by local authorities, had not been reported to CQC”
incident learning
1 finding
moderate“outcomes of safeguarding incidents were not always clearly documented which meant there was a risk the service did not effectively reflect on what went wrong”
staff training
1 finding
moderate“the majority of staff had not completed or refreshed their health and safety and fire safety training”
record keeping
1 finding
moderate“for 1 former staff member, the management team had not completed a risk assessment around issues on their DBS to demonstrate they were suitable to work with vulnerable people”
staffing levels
1 finding
minor“relatives did comment about the use of agency staff within some of the projects. This meant that people did not always receive care and support from a consistent staff team.”
supervision appraisal
1 finding
moderate“supervision meetings had taken place, these had not been carried out consistently and on a regular basis in accordance with the service's policy.”
consent capacity
1 finding
moderate“some staff demonstrated a limited knowledge of what might constitute a deprivation of liberty.”
staff competency
1 finding
minor“The service did not observe medicine competencies of staff which was highlighted to the operations and area manager.”
leadership
1 finding
minor“The registered manager...was no longer with the company and was due to submit their de-registration application.”