Prospects for People with Learning Disabilities - 3 Norwich Road

Social Care Org · East

Overall Rating
Requires Improvement Last inspected 12 April 2017
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

1 must-do action
5 should-do actions

Must-Do Actions (1)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Well-led
There was a lack of robust systems in place to routinely monitor and assess the quality of the service being delivered. The registered manager did not audit people's care records or people's medicines. The registered manager did audit the weekly health and safety checks but did not provide an action plan for any shortfalls found. Any remedial action was not taken in a timely manner. A member of the provider's quality assurance team conducted an internal monthly quality audit, again these were ineffective at addressing concerns within the service. People's care records and medicines were not audited and we noted from the health and safety audit that where concerns had been identified, an action plan was not put in place. There were no audits of people's care records and medicines. We identified that in one person's records, they had been referred to by the wrong name on numerous occasions and this had not been identified.
Regulation 17 (Good governance)

Should-Do Actions (5)

Recommended improvements to enhance service quality.

Should Do
Effective
A number of staff were not up to date with their training. Four staff did not have up to date training in the Deprivation of Liberty Safeguards and two staff had not received training in the Mental Capacity Act (2005). One member of relief staff had not received training in food hygiene, health and safety and fire safety.
Should Do
Effective
Staff who worked on an as and when basis did not receive any regular formal supervision despite the fact they worked at the home a couple of times a week.
Should Do
Responsive
People's care plans were not always written in a person centred way. In one care plan the person's name was incorrect on a number of occasions in their care plan. Some of the information in people's care records was duplicated across all three people's care plans we looked at.
Should Do
Well-led
Staff meetings were not as regular as they would like them to be. It was difficult to arrange a time when most of the staff would be able to attend. There was still a poor turn out at the meetings and there were no minutes from these meetings.
Should Do
Well-led
It is good practice to seek regular feedback from people who use the service and any other people involved in the service, such as, relatives, friends and professionals. This gives the provider information about what the service does well and what could be done better. The provider could then take steps to address any issues that arose as a result of the feedback.
Location Details
CQC ID: 1-111991486
Local Authority: Norfolk
Region: East
Inspection Report
Type: Comprehensive inspection
Date: 12 April 2017
Rating: Requires Improvement
Actions: 1 must-do , 5 should-do
AI-extracted 17 Feb 2026