critical“Care plans and risk assessments were not updated from incidents that had occurred. Another person's environmental risk assessment did not identify the risk and how that impacted the person.”
safeguarding
1 finding
critical“The risk assessment also stated the person did not have a smoke alarm in their property, which is a high risk of the person becoming harmed from a fire.”
staff training
1 finding
critical“Staff did not receive training in supporting people with a learning disability, autism or mental health and dementia. This was a breach of Regulation 18.”
governance
1 finding
critical“The provider had failed to ensure governance systems were established and operating effectively to ensure oversight was robust. This was a breach of Regulation 17.”
incident learning
1 finding
moderate“The provider did not have effective systems in place to ensure that learning from incidents and accidents were being recorded in people care plans and risk assessment.”
person centred care
1 finding
critical“The care and treatment of people using the service did not always match their needs. This was a breach of Regulation 9.”
record keeping
1 finding
moderate“People's care information lacked detailed information, which meant there was a risk people would not receive the care that met their needs and preferences.”
consent capacity
1 finding
moderate“The provider's initial assessment did not cover people's mental capacity, which meant that the provider was not always working in line with the MCA.”
leadership
1 finding
moderate“The registered manager was not always fully aware of the needs of people they supported. A person's needs assessment did not identify they had autism.”
complaints handling
1 finding
minor“The provider informed us that they had not received any complaints. However, we identified that concerns had been raised about staff not logging in and out from their care visits.”