Creative Support - Leicester Service received an overall Good rating following its December 2022 inspection, with Safe rated Requires Improvement due to insufficient staffing at one site, unrecorded injuries, and medication omissions. Well-led remained Good, reflecting strong leadership, person-centred culture, and effective governance systems.
Concerns (7)
criticalStaffing levels: “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.”
criticalSafeguarding: “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.”
moderate
Incident learning
: “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.”
moderateRecord keeping: “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.”
moderateMedication management: “From reviewing incident records, we identified incidents of medicine omissions had occurred due to staff error.”
minorInfection control: “We noted a staff member wearing jewellery and another wearing nail varnish. This posed an infection and safety risk.”
minorCare planning: “There were some inconsistencies in where guidance was recorded in relation to health conditions... it was not always easy to find information.”
Strengths
· People received personalised care with independence promoted and goals and aspirations supported.
· Strong positive culture with staff showing clear commitment to person-centred, high-quality care.
· Effective safeguarding training in place; staff understood how to recognise and report abuse.
· Safe staff recruitment procedures including DBS checks and targeted recruitment campaigns.
· Robust governance systems including audits, senior manager reviews, and incident theme analysis.