critical“Systems were not operated effectively to identify where people may have experienced abuse or been put at risk of harm. It had not been identified that some people had been subject to degrading treatment”
critical“Following our inspection, we made nine safeguarding referrals to the Local Authority that had not been identified by the service to ensure people were safely protected from harm.”
consent capacity
2 findings
critical“People were subject to daily restrictions such as limited use of technology, restrictions on what they could spend their money on and restrictions around food. No mental capacity assessments had been completed”
critical“Kazlum Support were managing people's finances on their behalf without the legal authority to do so.”
person centred care
2 findings
critical“Peoples care was not always delivered in line with standards, guidance and the law. This was a breach of Regulation 9”
critical“Positive behaviour systems had been used in a negative and punitive way. Records showed staff using 'star' rewards and the removal of treats as punishment.”
governance
2 findings
critical“Governance processes were ineffective and did not hold staff to account, keep people safe, protect their rights or ensure good quality care and support.”
critical“There were no systems in place to audit care records, which meant managers did not analyse information to ensure people were supported in line with their support plans”
leadership
2 findings
moderate“The Registered Manager had limited involvement in the day to day running of the service and did not participate in this inspection process.”
moderate“Management were defensive of poor and outdated practice, and written records indicated a culture which lacked respect for people”
care planning
1 finding
moderate“There was insufficient information within people's support plans to enable staff to effectively support and understand their mental health needs.”
staff training
1 finding
moderate“Training records indicated staff should complete Mental Capacity Act training every three years, however, 13 out of 34 staff had not completed the training within the past three years.”
incident learning
1 finding
critical“they had not identified themes and trends of positive behaviour systems being used in a punitive way, nor recognised this as abuse.”
medication management
1 finding
minor“there were no audits undertaken or checks of medicines recorded.”
staffing levels
1 finding
moderate“There aren't enough staff at this house as a few have left and they haven't got any more staff for our house.”
communication with families
1 finding
moderate“The service did not always act on the duty of candour appropriately.”
record keeping
1 finding
moderate“Notifications were not always submitted to CQC in line with the regulations.”