critical“Assessments of people's capacity to make specific decisions, for example on medicines or mechanical restraint, had not always been completed and best interest meetings had not been arranged in line with MCA principles.”
governance
1 finding
critical“The provider's governance systems were not always effective...they had failed to identify the concerns we found at inspection in relation to the Mental Capacity Act, staffing levels and staff supervisions.”
supervision appraisal
1 finding
moderate“Supervisions were not consistent across the service...Comments from staff included, 'We have nothing official' and, 'There is nothing documented'.”
staffing levels
1 finding
moderate“There were not always enough staff on duty to provide 1-1 support for people to access the community or attend medical appointments...community leave and medical appointments were often cancelled.”
record keeping
1 finding
moderate“Records were not always accurate, up to date or contain relevant information...a person's support plan still contained information they required pressure care on a daily basis, this was no longer the case.”
person centred care
1 finding
moderate“People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.”
communication with families
1 finding
minor“People and their relatives were not fully engaged with the running of the service. Relatives told us they did not attend regular meetings with other families and did not get asked for feedback.”
care planning
1 finding
minor“Support plans contained information that did not always relate to a person's care. For example, medication support plans contained information about the systems and processes of ordering medication.”