critical“Systems had not been established to assess, monitor and mitigate risks to the health and safety of people using the service. This placed people at risk of harm.”
critical“Systems had not been established to monitor and improve the quality of the service. This was a breach of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
staff training
2 findings
moderate“Some staff had not completed training around how to ensure people were safe. The registered manager was aware of the issues with staff training.”
minor“Although staff had completed training, some training updates were overdue due to issues caused by the pandemic.”
leadership
2 findings
moderate“The registered manager also lacked knowledge around some areas of their responsibilities in relation to assessing the safety of the service.”
moderate“the management team in the home did not have the knowledge and experience to perform their role. They had not ensured best practice in supporting people who have a learning disability was followed.”
person centred care
2 findings
critical“People's care was not always person-centred. People did not receive care that supported their needs and aspirations, or that focused on their quality of life”
critical“People were not supported to be involved in their community. This was a breach of regulation 10(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
care planning
1 finding
critical“Some risks had not been assessed and some risk assessments were not robust. Some checks on the safety of equipment had not been carried out.”
complaints handling
1 finding
moderate“Although staff had raised concerns on behalf of people regarding the lack of activities in the community, the provider had not treated this as a formal complaint and had not acted to improve the service.”
staffing levels
1 finding
moderate“staffing levels had not been arranged to support people to have regular access to the community”
communication with families
1 finding
moderate“People, and those important to them, had not been included in developing and improving the service. The provider had not gathered and acted on people's feedback”