critical“People are not leaving their home and do not get the one to one staff they need. We end up just doing the basics to make sure that people are safe.”
governance
1 finding
critical“Audits were not effective in putting actions in place where improvements were needed regarding people's lived experience in the service.”
person centred care
1 finding
critical“Staffing levels were not being provided in line with people's assessed needs and preferences. This meant that people were not always receiving their one to one support.”
leadership
1 finding
critical“Staff told us that senior leaders had told them not to give us any negative feedback during the inspection process.”
staff training
1 finding
moderate“Staff told us they would like more specific training about supporting autistic people and people living with a learning disability, particularly around different ways of communicating.”
supervision appraisal
1 finding
moderate“Some staff were not receiving regular supervision to support their continual development and training. It does not happen regularly. Certainly not recently as we have been so short staffed.”
medication management
1 finding
moderate“Some people had protocols in place for 'as and when required' (PRN) medicines, however, some of these were not specific to the person and did not give clear guidance.”
infection control
1 finding
moderate“There was a noticeable build-up of dust and cobwebs, as well as visible food stains on the walls of people's bedrooms.”
care planning
1 finding
moderate“Support plans in place for people did not always contain detailed information about goals and aspirations, or how to promote people's independence.”
consent capacity
1 finding
moderate“Some capacity assessments indicated that these were completed solely by members of the persons support staff, without any involvement from family, advocates or other professionals.”
communication with families
1 finding
minor“Relatives told us they tended to speak to staff at their family members home and were unsure who to contact from the management team.”
record keeping
1 finding
minor“The way that staff described people in documents such as daily records and support plans did not always show dignity. People were described as being 'fed' when being supported to eat.”