critical“assessments did not cover all needs related to equality and diversity. For example, they did not cover needs related to ethnicity, gender or sexuality.”
governance
1 finding
critical“monitoring systems were not always effective...reviews had failed to identify shortfalls with care plans in relation to sexuality or the fire evacuation risk assessments”
person centred care
1 finding
critical“The registered person had failed to carry out a comprehensive assessment of the needs and preferences for care of the service users. Specifically, they had failed to assess all relevant needs related to equality and diversity.”
cultural competency
1 finding
moderate“pre-care assessments and care plans did not fully cover people's needs in relation to equality and diversity.”
communication with families
1 finding
moderate“staff opened the door and came in without knocking first...one staff member said of an adult who used the service, '[Person] is like a small baby, so we need to treat them like a baby.'”