critical“Staffing levels were not consistently sufficient to meet people's individual needs. The commissioned hours provided at 1 supported living site did not meet the dependency needs of the 3 people living at the service.”
safeguarding
1 finding
critical“Two body maps dated May 2022 and December 2022 showed the same person had an injury, but this was not recorded in the incident records.”
incident learning
1 finding
moderate“The injury was not recorded in the person's daily notes or staff handover document. It was therefore not clear how the injuries had occurred.”
record keeping
1 finding
moderate“Agency staff profiles were not routinely kept at the individual supported living sites. This was important to enable staff to check agency staff identity when arriving for work.”
medication management
1 finding
moderate“From reviewing incident records, we identified incidents of medicine omissions had occurred due to staff error.”
infection control
1 finding
minor“We noted a staff member wearing jewellery and another wearing nail varnish. This posed an infection and safety risk.”
care planning
1 finding
minor“There were some inconsistencies in where guidance was recorded in relation to health conditions... it was not always easy to find information.”