critical“one person's risk assessment was due for a six monthly review but had been left for 11 months. Another person's protocol about their emergency epilepsy medicine was incomplete”
staffing levels
1 finding
critical“despite two staff being needed to support one person with their mobility needs, there were parts of the day when only one staff member was on duty”
governance
1 finding
moderate“The issues we raised about the management of people's epilepsy and the staffing of one of the supported living services had not been proactively explored by the registered manager.”
record keeping
1 finding
moderate“Care plans did not instruct staff to check in this way. Risk assessments stated staff should check people each hour, but did not specify how.”
incident learning
1 finding
moderate“we questioned the lack of timeliness in carrying out a thorough review of all plans and all risks relating to epilepsy”
person centred care
1 finding
minor“decisions about how to carry out night checks to keep people safe whilst ensuring their privacy needed review”