critical“Known risks associated with people's care and support were not always assessed. One person had epilepsy, but an epilepsy risk assessment had not been completed”
critical“One person's accessing the community risk assessment instructed staff to 'take reasonable actions' to keep the person safe if they ran out into the road.”
medication management
2 findings
critical“Protocols for those medicines were not in place for staff to follow to ensure people received their medicines when they needed them in line with national medicines guidance.”
moderate“a check of medicines during January 2022 had not identified a staff signature was missing to confirm administration of a medicine”
governance
1 finding
critical“Systems were not established or operated effectively to assess, monitor and improve the quality and safety of the service.”
record keeping
1 finding
critical“accurate, complete records in respect of each person were not maintained. This was a breach of Regulation 17 (Good Governance)”
infection control
1 finding
moderate“The individual characteristics of staff including staff from Black, Asian and Ethnic Minority groups (BAME) had not been assessed to ensure staff were kept as safe as possible at work during the COVID-19 pandemic”
safeguarding
1 finding
critical“we had not been notified of an allegation of abuse that had occurred in September 2021. The statutory notification was submitted retrospectively following our request.”
consent capacity
1 finding
moderate“further information needed to be added to care records to ensure people's care and support was consistently provided in line with the requirements of the Act.”
communication with families
1 finding
minor“Whilst the AIS standards to support people's needs had not been fully considered during care planning”
cultural competency
1 finding
minor“The registered manager was in the process of adding further information to people's care records in relation to their cultural needs and preferences”
leadership
1 finding
moderate“managerial oversight of the care and support provided needed to be strengthened to demonstrate good quality safe care was always provided.”