critical“care plans did not contain an assessment to show people's capabilities and to determine what support they required...lacked detail on how episodes of low blood glucose...would be managed”
incident learning
1 finding
critical“one person at high risk of falls had 21 falls between April 2020 and July 2021. However, the corresponding notes repeated the same account 21 times”
governance
1 finding
critical“there were no effective quality assurance procedures...the provider could not provide us with a programme of effective regular audits to assess the quality of key areas of service”
record keeping
1 finding
critical“A risk assessment was in the name of another person. Two out of the three sections of the assessment were in a wrong person's name.”
person centred care
1 finding
moderate“staff refused to prepare or serve pork products on the grounds of their own cultural and religious beliefs. People had to rely on visiting relatives or others”
supervision appraisal
1 finding
moderate“development plans and objectives agreed during appraisals were not followed up...the same goal was identified in subsequent appraisals over the next four years”
communication with families
1 finding
moderate“care plans for people with learning disabilities, who were unable to communicate their needs verbally, did not give staff a range of techniques or options for communication”
safeguarding
1 finding
critical“sufficient urgent steps had not been taken to keep the person safe. This meant there was a delay in early identification of underlying causes. We raised a safeguarding concern”
medication management
1 finding
minor“these had not identified staff were not recording reasons for giving PRN medicines. An entry must be made in the people's care record detailing the reason why the 'PRN' dose was given”
leadership
1 finding
moderate“There was no evidence the provider had involved people or other stakeholders to develop or improve the service since they were registered in December 2020.”