Note30 Oct 2021
The provider worked collaboratively with external agencies including safeguarding authority and community health teams.
Note30 Oct 2021
The provider was open and co-operative during the inspection and receptive to feedback.
Note30 Oct 2021
The service had a diverse staffing team with regard for the Equality Act and people's cultural and religious backgrounds.
Note30 Oct 2021
People were supported to access health and social care professionals promptly, with hospital passports in place.
Note30 Oct 2021
Staff understood and worked in accordance with the Mental Capacity Act 2005 and DoLS principles.
Note30 Oct 2021
People were supported to make their own meals, go shopping, and develop independence skills.
Note30 Oct 2021
Staff were kind, caring and friendly; consistently praised by people and relatives.
criticalstaff_competency30 Oct 2021
One member of staff did not know that one person they supported regularly had a diagnosis of epilepsy whilst another member of staff was unaware of a person at risk of self-harm.
moderatecomplaints_handling30 Oct 2021
We were also told that no complaints had been received so there were no records available...the provider had not yet routinely sourced feedback by way of surveys or questions.
moderatecommunication_with_families30 Oct 2021
Some of the relatives we spoke with were unaware of this change [manager departure]...relatives confirmed that better communication systems were required.
minorperson_centred_care30 Oct 2021
We advised that they needed to avoid a 'blanket approach' as this placed them at risk of compromising person-centred care.
moderatesupervision_appraisal30 Oct 2021
Staff we spoke with confirmed that they received 'regular' supervision and attended staff meetings, but the frequency of these could not be determined because no records were available.
criticalincident_learning30 Oct 2021
Notifiable incidents had not always been reported to CQC as required by law...incidents that had involved the police [were not notified].
moderatestaffing_levels30 Oct 2021
A relative we spoke with told us that staffing levels at night caused them some concern...a member of night staff walked out and left the service un-staffed.
moderatemedication_management30 Oct 2021
Some people had been assessed as requiring medicines on an 'as required' basis...others did not [have protocols]. Care records did not always reflect people's medicine administration records.
moderatestaff_training30 Oct 2021
Staff we spoke with told us that they felt the training offered to them by the provider required improvement...Training records were not available for us to view.
criticalcare_planning30 Oct 2021
The provider had failed to update this information following a review with the GP. This meant staff had very little information concerning this person's seizure history.
criticalsafeguarding30 Oct 2021
Records we looked at referred to incidents that should have been raised as safeguarding alerts but instead the provider had reviewed peoples care plans and risk assessments.
criticalleadership30 Oct 2021
There had not been a registered manager in post since June 2017. This is an offence under section 33 of the Health and Social Care Act 2008.
criticalrecord_keeping30 Oct 2021
A common theme throughout the inspection...was poor record keeping and ineffective quality monitoring systems and processes.
criticalgovernance30 Oct 2021
Inconsistencies within the provider's quality monitoring practices had failed to identify or remedy the shortfalls we found within the service, which collectively formulated a breach of Regulation 17
Note30 Oct 2021
The provider was co-operative during the inspection and working with external agencies including the local safeguarding authority.