critical“The provider was not able to evidence they had an effective system to investigate and analyse incidents.”
medication management
1 finding
critical“One person had a specific PRN medicine...the staff had not been trained or assessed as competent to complete this task.”
consent capacity
1 finding
critical“Each person's records had a range of consent forms that had been signed by their relatives, even when the person had been assessed as having capacity.”
governance
1 finding
critical“The concerns we found on the inspection...were not identified through the provider's own quality monitoring systems.”
record keeping
1 finding
moderate“Some of the incident forms were not completed fully. It was not clear what remedial actions were taken including review of incidents, risks and outcomes.”
care planning
1 finding
critical“Support plans did not include clear guidance for staff in what circumstances people should be restrained or use restrictive practices.”
staff training
1 finding
moderate“Some of the staff required to complete their training to ensure they were able to support people with different conditions such as epilepsy, mental health, restrictive practices.”
safeguarding
1 finding
moderate“Staff did not demonstrate they had the knowledge and understanding they did everything they could to avoid restraining people.”