critical“Medicine administration records had not been accurately completed and staff had not been provided with clear guidance on the use of 'as required' and emergency medicines.”
critical“We found multiple examples in all 3 settings where there were unexplained gaps in MAR charts.”
consent capacity
2 findings
critical“Staff and managers did not fully understand their roles in assessing people's capacity to make specific decisions.”
critical“Where people lacked capacity...restrictions to people's freedoms were in place...this information had not been appropriately reported to the local authority.”
care planning
1 finding
moderate“People's care plans were incomplete and missing information on how to manage risks, including in relation to mobility needs and specific medical conditions.”
governance
1 finding
moderate“The service is required to have a registered manager but there was no registered manager in post at the time of this inspection.”
leadership
1 finding
moderate“"We've had an insane high management turnover", "Management has been a mess" and "There has been a lot of management change, I think I am on my 4th or 5th manager".”
person centred care
1 finding
moderate“2 of the 3 settings inspected were operating as if they were care homes as opposed to supported living settings...Rolling staff rotas...restricted people freedoms and choices.”
record keeping
1 finding
moderate“Handwritten amendments and changes to MAR had not been countersigned to ensure the accuracy of the information transcribed.”
supervision appraisal
1 finding
minor“"I have had supervisions" and "[The new manager] has done supervisions, I had not had one before".”