critical“One person was found to be restrained by staff without legal authority. A staff member told us the person gets angry when they are restrained, indicating restraint caused the person distress.”
critical“the provider's systems and processes placed people at increased risk of avoidable abuse and improper treatment. This was a breach of Regulation 13 (Safeguarding)”
medication management
2 findings
critical“None of the people being supported with medicines had Medicine Administration Records (MAR) Charts in place. People were at risk of overdose as staff did not have enough information to administer these safely.”
critical“the provider failed to ensure the proper and safe management of medicines.”
care planning
2 findings
critical“Risks to people using the service were not assessed or mitigated. For example, a person was at high risk of falls. The registered manager advised inspectors that the person fell most days. However, there was no falls risk assessment in place.”
critical“the provider failed to identify and mitigate serious risks to people's health, safety and wellbeing. This was a breach of Regulation 12 (Safe care and treatment)”
staff competency
2 findings
moderate“Some staff competency assessments had been completed, however, they failed to evidence how the member of staff had demonstrated competence in each specific area.”
moderate“References from some previous health and social care settings had not been in place.”
governance
2 findings
critical“There was a lack of robust systems and processes within the service to monitor and review the quality of service people received, along with a failure to effectively respond to and record improvements.”
critical“Systems and processes had not been established or operated effectively to ensure a quality service. This was a breach of Regulation 17 (Good governance)”
staff training
1 finding
critical“Staff did not always have the training and skills to support the people they worked with. This included some staff failing to have received training in areas such as first aid, adult and child safeguarding, moving and handling, and medicines.”
supervision appraisal
1 finding
moderate“The provider was unable to evidence that they were regularly supporting staff through supervisions, appraisals and spot checks.”
leadership
1 finding
critical“A closed culture was prevalent within the service. Examples included the workforce comprising of family members or close friends, restrictive practices being used, and unsafe staff recruitment practices.”
consent capacity
1 finding
critical“Where people were deemed to lack capacity, formal assessments had not been carried out to assess whether they needed support with decision making. Staff had no guidance in place.”
person centred care
1 finding
moderate“People's care plans lacked information to help staff get to know people well, including people's preferences, personal histories and backgrounds.”
communication with families
1 finding
minor“The provider was unable to demonstrate robust systems in place to seek views about the quality of the service from people, or their relatives.”
record keeping
1 finding
moderate“There was a lack of order in record keeping and some documents, audits and checks we asked for could not, or were not, made readily available to us.”
incident learning
1 finding
critical“The registered manager failed to understand their duty to be open and honest when things went wrong. Multiple safeguarding incidents had occurred within the service however, these were not shared with both the CQC, and external healthcare professionals.”