moderate“Assessments did not always include people's ability to make decisions or who made decisions on people's behalf, if they were unable to do this themselves.”
moderate“Not all the people who required 24 hour supervision had applications submitted. Where people lack capacity to make decisions and are continually supervised, an authorisation to restrict their freedom should be applied for.”
record keeping
1 finding
minor“The managers said they would make sure copies of assessments were obtained. They said they would also include this in their initial assessment procedure to ensure copies were requested in future.”
governance
1 finding
moderate
“They were not aware of all the notifications they were required to send to us when reportable incidents had occurred. We found one incident where a person had a serious injury that we had not been told about.”