Note9 Mar 2023
Cultural and religious needs were recognised and steps were being taken to support people's practices.
Note9 Mar 2023
Staff used diverse communication methods including Makaton, pictorial aids and symbol-based tools.
Note9 Mar 2023
New quality assurance framework and incident reporting system introduced to improve governance oversight.
Note9 Mar 2023
New registered manager and senior leadership team were actively engaging with issues and implementing improvements.
Note9 Mar 2023
Staff at several settings showed dedication and commitment to people's independence and wellbeing.
Note9 Mar 2023
Some settings fostered a culture of reflective practice and shared learning from incidents.
Note9 Mar 2023
Infection prevention and control practices were assured across all settings.
Note9 Mar 2023
Recruitment processes were safe with appropriate DBS and relevant checks completed for all staff.
minorsupervision_appraisal9 Mar 2023
I'm currently taking the time to do their supervisions and appraisals so I can show them the standards that are expected.
moderateincident_learning9 Mar 2023
Multiple management changes, alongside staffing shortages had meant that a culture of learning from events had not yet been established.
moderatecare_planning9 Mar 2023
The assessment process had not been used effectively to ensure services were only offered where people's needs could be fully met.
moderatestaff_training9 Mar 2023
Staff turnover was so high... this learning had not always been successfully embedded.
moderatecomplaints_handling9 Mar 2023
At one setting in particular, people said they had given up raising complaints because nothing was ever done.
moderatestaff_competency9 Mar 2023
Some of the settings relied on high levels of temporary staff who did not always have the skills and experience to meet people's needs and expectations.
criticalperson_centred_care9 Mar 2023
People did not consistently receive care that was person-centred... they had to prioritise the needs of the group, rather than the individual.
criticalgovernance9 Mar 2023
The provider had failed to establish systems and processes that appropriately assessed, monitored and improved the quality and safety of people's care.
criticalmedication_management9 Mar 2023
One person had been prescribed eardrops for 7 days, but staff continued to administer it for 11 days.
criticalstaffing_levels9 Mar 2023
People across all settings repeatedly told us there were not enough staff to meet their needs... waiting for your care. Sometimes I go to bed much later than I would like to.
criticalsafeguarding9 Mar 2023
People did not consistently feel safe in their homes... people also told us they did not feel safe with some of the staff that supported them.