moderateconsent_capacity19 Aug 2022
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
moderatesupervision_appraisal19 Aug 2022
There were no records of staff meetings and records relating of supervision did not demonstrate how the provider had engaged with staff to seek feedback and drive improvement.
moderatecommunication_with_families19 Aug 2022
They're always late. We get a phone call much later than the call time saying they are going to be late. I just expect it now.
criticalleadership19 Aug 2022
widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care
criticalgovernance19 Aug 2022
The provider had failed to implement and operate effective systems to monitor the quality and safety of the service.
criticalincident_learning19 Aug 2022
The provider had no systems in place for recording of incidents or accidents. Accidents and incidents were not monitored.
criticalrecord_keeping19 Aug 2022
people's daily records were not always completed. This lack of review meant concerns about people's care and support needs were not always known and responded to.
criticalcare_planning19 Aug 2022
Risks to people were not assessed, recorded, managed and reviewed regularly.
criticalstaff_competency19 Aug 2022
one member of staff had worked without supervision before the recruitment process had been completed.
criticalstaffing_levels19 Aug 2022
The provider had failed to ensure that there were sufficient numbers of staff deployed to meet the needs of people using the service.
criticalsafeguarding19 Aug 2022
we identified two concerns of potential financial abuse and three concerns of neglect. We raised safeguarding alerts in respect of our findings with the local authority safeguarding team.
criticalmissed_or_late_visits19 Aug 2022
The providers call monitoring system identified multiple missed and late visits. This meant that people were at risk of harm by not having their care and support needs met.
criticalmedication_management19 Aug 2022
Staff were administering medication without appropriate training or checks of their competency.
criticalstaff_training19 Aug 2022
Staff had not received any training in relation to the donning and doffing of PPE.
criticalinfection_control19 Aug 2022
The providers policy for COVID-19 had not been updated to reflect government guidance or best practice guidance.