critical“staff worked excessive hours without breaks during shifts or between shifts. They also slept at night when they were required to be awake. This increased the risk of potential harm to person.”
staff training
1 finding
moderate“only 2 out of 5 staff had completed training in learning disabilities and 1 staff member had completed training in de-escalation. Not all staff had completed the care certificate.”
care planning
1 finding
critical“care records were not reflective of the person's current needs. Risks associated with falls and critical health conditions needed to be sufficiently detailed with guidance in place.”
medication management
1 finding
moderate“Staff understood when to give the person 'when required' medicines, however protocols to dispense these types of medicines were not in place.”
governance
1 finding
critical“Governance processes needed further development to ensure they encapsulated all aspects of the service. There were gaps in some of the audits completed for medicines and record keeping.”
record keeping
1 finding
critical“accurate, complete and contemporaneous records were not in place. This is a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008.”
leadership
1 finding
moderate“The provider was not aware of guidance to support people with a learning disability and/or autism. They were also not aware of health and safety executive regulations to support staff at work.”