critical“The provider had not cooperated with the local safeguarding team and not provided the requested information. The provider had also not conducted their own investigation into the concerns raised.”
medication management
1 finding
critical“One person's MAR stated paracetamol was to be given '4 times a day as required' with no information about the dose or frequency.”
care planning
1 finding
moderate“Risk assessments and care plans contained unprofessional descriptions of people's behaviour that were not person-centred.”
staff training
1 finding
critical“Staff who were supporting someone at risk of having seizures had not received Epilepsy awareness and emergency medication training.”
governance
1 finding
critical“Quality assurance processes were in place but they had not been effective and had not identified the issues we found with care plans, risk assessments, medicines and staff training.”
person centred care
1 finding
moderate“There was very limited information in place about people's life history...a lack of information about how people were supported to follow interests and engage in activities.”
consent capacity
1 finding
moderate“The provider had not conducted a capacity assessment and there was no Court of Protection authorisation in place.”
incident learning
1 finding
moderate“There was no system in place to collate and analyse incidents.”
supervision appraisal
1 finding
moderate“There was also no record of staff appraisal in the files we reviewed... One member of staff told us, 'It's meant to be every 3 months. But this is not happening.'”
record keeping
1 finding
moderate“One person's risk assessment stated their medications should be administered via the PEG. This was outdated information as the PEG was removed in July 2022.”
leadership
1 finding
critical“The current and former nominated individual did not have an understanding of the responsibilities of registered providers under Right Support, Right Care, Right Culture.”