critical“Restrictions were placed on people without considering the principles of the MCA and there was not always clear evidence that the restrictions were in the person's best interest.”
consent capacity
1 finding
critical“The provider had failed to ensure care was provided to people in a way that ensured people were not unlawfully deprived of their liberty. This was a breach of Regulation 13.”
medication management
1 finding
critical“One person was prescribed medicines covertly. This had been agreed by the person's GP in 2018. Although we had been told this had been reviewed, there was no evidence of this.”
incident learning
1 finding
critical“Following 1 significant incident, staff involved did not receive a debrief for 7 weeks. This meant potential opportunities to learn lessons quickly when things went wrong, were lost.”
care planning
1 finding
moderate“Care plans, risk assessments and positive behaviour support plans were not always being followed. 1 person's support plan had not been reviewed since 31 July 2021.”
staff training
1 finding
critical“Staff told us they had not always received adequate training to support people who experienced emotional distress. Not all staff had received training required for physical intervention.”
governance
1 finding
critical“Several governance audits completed by service managers were found to be inaccurate, and had not identified the issues found during the inspection e.g. concerns with medication, training, MCA and DoLS.”
record keeping
1 finding
moderate“Records did not always detail what other options were considered or which option was the least restrictive. We found they had not always been reviewed.”
staffing levels
1 finding
moderate“Relatives told us, 'I am happy, or was, but there are not enough staff, and that's the crux of it' … registered manager was aware that commissioned hours were not always being met.”
person centred care
1 finding
moderate“1 record stated a person was requesting breakfast but was told they had to wait. Another record stated an incident occurred due to the person 'not getting their own way'.”
supervision appraisal
1 finding
minor“Staff received support in the form of continual supervision and team meetings, however this differed across the settings. Evidence was not always available to show when team meetings had been completed.”
complaints handling
1 finding
moderate“We saw 1 example of where a concern was raised by a person in July 2023. This had not been acknowledged or responded to.”