Working at Luke's Place

Staff twice ignored safety plans which put people at risk, and some medication notes missed details.

We found 2 occasions where staff had not followed people’s risk assessments which put people at risk. records for medicines used to manage some health conditions sometimes lacked detail.

No activities coordinator or specialist programmes, just basic outings, hobbies and sensory activities.

People were supported to take part in activities that were meaningful to them, such as attending social groups, or pursuing hobbies.

Audits and fixes from lessons learned are not always followed through or shared with the team quickly.

there was not always evidence the lessons learnt were embedded into the service in a timely way... where improvements had been identified, there was not always clear action plans or evidence to show actions were embedded