moderate“Care plans and risk assessments were inconsistent and did not always detail the relevant information staff would need to meet people's assessed care and health needs.”
moderate“People's needs and choices had been assessed when they started using the service, but changes to their needs had not consistently been identified or planned for.”
minor“Care plans did not always fully reflect people's preferences. There was insufficient information recorded for staff to know how the person preferred to be supported, or their likes or dislikes.”
staff training
2 findings
critical“Training records evidenced that staff did not complete the provider's mandatory training before they commenced their shadowing shifts, induction and work.”
minor
“We found one staff member whose medicines training had expired.”
record keeping
2 findings
moderate“Medicines records from December 2021 had been returned to the office for checking but had not yet been checked.”
moderate“The risk assessments we saw were not robust and merely described potential harm to people. There was no corresponding mitigation of the hazard via effective control measures.”
safeguarding
1 finding
critical“Two people had reported to the registered manager that a staff member had stolen from them. The registered manager had not reported this to the local authority following the local authorities safeguarding protocols.”
medication management
1 finding
critical“MAR records did not list which medicines staff were giving. One person's MAR showed that staff had been giving a different amount of medicines to what was listed on the MAR.”
staff competency
1 finding
critical“'A few times someone has come with no hoist (standing hoist) experience and I have had to talk them through this.'”
governance
1 finding
critical“Audits had not picked up shortfalls in practices in relation to risk assessment, safeguarding, medicines management, staff recruitment, training, care planning, recording and notifications.”
incident learning
1 finding
moderate“One person had fallen and injured themselves in January 2022 and had been found by a staff member. This had not been appropriately recorded.”
communication with families
1 finding
minor“'TerraBlu have been very stretched lately so the times of calls are all over the place. They always turn up but don't always let me know.'”
person centred care
1 finding
moderate“Care plans for people with a learning disability and or autism were not structured to support people to achieve their goals and aspirations.”
supervision appraisal
1 finding
minor“Staff received supervision from their line manager but did not have annual appraisals to review their learning or reflect on their performance.”