Adrian O'Brien Rachel Amiee O'Brien - 122 Scorer Street

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At this assessment we did not assess all quality statements within this key question. We assessed 1 quality statement in the well-led key question. We found 1 breach of legal regulation relating to the management of the service. Systems and processes were ineffective in ensuring records were regularly reviewed. Care plans and other records did not contain the most up to date information and risks were not always assessed. The provider had not acted in line with contingency plans to ensure the service remained safe when there were unexpected staff shortages. The provider did not have robust systems to monitor or improve the quality of care.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with told us they felt supported by the registered manager. Staff told us they completed care plan reviews and other regular audits but admitted these were not up to date due to the unforeseen staffing situation.

There were no clear or effective governance, management and accountability arrangements. Due to the shortage of staff, the registered manager and quality manager told us they had not been able to carry out their management roles. There had been no consideration for ensuring effective management and governance during the period of short staffing. The provider had not acted in line with their own contingency plans to ensure the service remained safe when there were unexpected staff shortages.

Audits had not been effective in identifying the concerns we found during this assessment. For example, medicine errors had not been identified so actions had not been taken to reduce the risk of reoccurrence.

There were no robust processes to analyse incidents to identify any learning with staff. The service relied on police support to manage a person in distress which did not support positive outcomes for the person and furthermore, incident forms showed police and staff had been harmed during these incidents. Processes were not in place to assess and support people’s psychological well-being following incidents and periods of distress.

Statutory notifications were not being made to the Care Quality Commission (CQC). We found the provider had not made us aware of police involvement in incidents. Providers must ensure notifications have been sent to the CQC for all incidents that affect the health, safety and welfare of people who use services as soon as possible after the event. We will continue to monitor and follow this up.

Following the on-site assessment the registered manager had created an action plan with some actions they had taken after feedback. However, there were still areas of concern that required addressing to ensure they were meeting required regulations and achieving good outcomes for people.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.