moderate“parts of the quality monitoring systems needed to be further developed to cover all areas of the service. For example, the provider's recruitment audits had not identified that health questionnaires had not been completed by all staff.”
critical“The provider had failed to ensure effective governance systems were being used to drive improvements. This was a breach of regulation 17 (Good governance).”
record keeping
2 findings
moderate“the records of their analysis of incident records had not been consistently maintained.”
moderate“Without accurate and concise record keeping by staff, the team leaders and registered manager may miss opportunities to review people's needs and seek appropriate support.”
care planning
2 findings
moderate“details of people's routine appointments, any recommendations and next review dates were not always clearly documented. The manager acknowledged that further development was needed in this area.”
critical“People's care plans did not always provide staff with personalised information such as their preferences, wishes and aspirations.”
incident learning
2 findings
moderate“Incident reports relating to the monitoring of people's behaviours and health such as patterns in people's seizures or emotions were reviewed and known by the managers. However, the records of their analysis of incident records had not been consistently maintained.”
moderate“The provider could not be assured that timely actions had been taken to prevent further reoccurrence as there was limited evidence that the outcomes and actions taken as a result of investigations had been completed.”
leadership
2 findings
moderate“At the time of our inspection there was no registered manager in post, however a new manager had been employed and supported this inspection.”
moderate“The roles and responsibilities of the management team were not clear which had resulted in conflicting decisions on how the service should be managed.”
medication management
1 finding
critical“The management and administration of people's routine prescription, 'as required' medicines and medicines prescribed mid cycle such as antibiotics were not complete and accurately recorded.”
consent capacity
1 finding
critical“The assessment of people's mental capacity to make specific decisions about their care and any associated unwise or best interest decisions on their behalf had not been completed.”
person centred care
1 finding
critical“People did not always receive care and treatment which was based on evidence based assessments...put people at risk of not receiving personalised care.”
staff training
1 finding
moderate“Staff told us the training they had received to support people with heightened emotions or distress was not adequate to support people with complex behavioural needs.”
staff competency
1 finding
critical“The registered manager was unable to demonstrate how they had ensured themselves that agency staff who supported people had been suitably vetted and had the skills they required.”
infection control
1 finding
moderate“Staff did not always wear PPE in accordance with current government guidance. This put people at risk of the spread of infection.”
communication with families
1 finding
minor“Others commented that communication from the service could improve, especially when they had raised concerns about the quality of care.”