Note13 Jul 2023
Provider allocated additional resources including operations manager two days per week and nominated individual spot checks.
Note13 Jul 2023
People's cultural and religious needs were considered in support plans with family involvement in planning.
Note13 Jul 2023
Provider and manager had good understanding of duty of candour with policy and procedure in place.
Note13 Jul 2023
New manager appointed February 2023 recognised positively by staff, relatives and external professionals.
Note13 Jul 2023
Management team responded immediately during inspection and submitted an action plan to address care record quality.
Note13 Jul 2023
People supported to have maximum choice and control and to access the community as and when they wished.
Note13 Jul 2023
Provider used the Positive Behaviour Support (PBS) model with detailed proactive and reactive strategies where assessed.
Note13 Jul 2023
Safe recruitment procedures in place including pre-employment checks, references and DBS certificates.
Note13 Jul 2023
Most staff appeared to know people well and understood their support needs despite gaps in documentation.
Note13 Jul 2023
Sufficient staffing levels deployed to meet people's needs, recently increased with a business case to further improve night-time arrangements.
moderatestaff_competency13 Jul 2023
The service supported people with a learning disability and/or autism, yet only half of the staff were trained in this area.
moderatecommunication_with_families13 Jul 2023
One professional said, 'It can be a little challenging to get any updates from staff members about people when reviewing (their care and support). Often staff don't know much about the person.'
moderateperson_centred_care13 Jul 2023
Some staff were not following people's positive behaviour support plans to ensure they followed all preventative and reactive strategies to enhance people's quality of life.
minorinfection_control13 Jul 2023
We found built up dirt and grime in shared bathrooms, kitchens, food cupboards and fridges.
moderatemedication_management13 Jul 2023
During the inspection we found 2 instances where medicines had not been safely stored...People's medicine support plans did not promote safe and personalised support as these had not been reviewed.
criticalleadership13 Jul 2023
Inconsistencies in leadership led to serious shortfalls in the provider's quality assurance processes...processes to identify risk and ensure the service was operating within the scope of regulations…
criticalgovernance13 Jul 2023
Systems were either not in place or robust enough to demonstrate quality and safety was consistently well-managed. This placed people at an increased risk of harm. Breach of regulation 17.