critical“Systems in place were not effective. They had not always identified the areas of concern we found at this inspection.”
moderate“some record keeping in the service such as staff induction, supervision and appraisals needed to be documented on a regular basis. Work was on-going with this and was being monitored by the local authority”
critical“the registered provider's quality monitoring system was ineffective and had not been used to measure or ensure the safety of people who used the service and staff.”
staff training
3 findings
critical“Staff had not received training to support people with their health conditions, such as epilepsy.”
moderate
“The induction for new staff was not in-depth, but did cover the basics of health and safety and working in the home. Work was on-going to embed more robust induction processes in the service.”
moderate“No staff had completed training on the Mental Capacity Act 2005 (MCA)...No staff had completed specialist training on learning disabilities.”
record keeping
3 findings
moderate“Records were not always fully completed or accurate. This included people's health records, supervision records, induction records and recruitment records.”
minor“handwritten entries on the MAR charts did not have two staff signatures to show that what had been recorded by the staff matched the instructions on the pharmacy label”
moderate“audits did not always contain any analysis of the information gathered or an action plan to show what action was being taken to improve the service.”
staffing levels
2 findings
critical“There were insufficient staff employed to run the service safely. The registered manager and acting manager were consistently on shift whilst also carrying out their own roles.”
moderate“there was no waking member of night staff even though some people who used the service had epilepsy and there was a risk they could have a seizure during the night.”
care planning
2 findings
moderate“Care plans had not been reviewed to ensure people's hobbies, interests and social needs were met during the pandemic.”
minor“there was no end of life information captured such as what people's wishes and choices would be in the event of their death.”
medication management
2 findings
moderate“One person had medication that was discontinued remained in their medication cabinet, and their prescribed creams had no opening or discard date.”
critical“staff were giving people their medicines, but not always signing on the medicine administration record (MAR) to show that it had been administered.”
supervision appraisal
2 findings
moderate“We looked at the supervision files for three members of staff and found that these were taking place, but not on a regular basis. We also noted that staff appraisals were not being completed on a yearly basis.”
moderate“no staff appraisals had been done for some time...the care manager...personal supervision was not taking place.”
infection control
1 finding
critical“Donning and doffing stations were not appropriately placed. They were in a high traffic area and not in separate areas to reduce the risk of contamination.”
person centred care
1 finding
critical“Blanket decisions were made as a service rather than on an individualised basis meaning people did not always receive care centred around them.”
staff competency
1 finding
moderate“Competency assessments were not carried out to ensure staff had the appropriate skills for their role.”
incident learning
1 finding
minor“Accident reports for the incidents that had occurred did not contain sufficient detail.”
consent capacity
1 finding
moderate“People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.”
safeguarding
1 finding
moderate“when we arrived at the service we were let in by a person who used the service. There were no staff in the main part of the building to ensure any visitors were safe to be in the building”
communication with families
1 finding
minor“Staff had limited skills in the use of Makaton to aid communication with people who used the service.”