critical“The provider was not working in line with the principles of the MCA. There was no evidence of consent to restrictions placed on people in some of the supported living houses we visited.”
governance
1 finding
critical“The provider's quality assurance systems and processes did not enable them to effectively assess, monitor and improve the quality and safety of the service.”
safeguarding
1 finding
critical“We found 1 occasion the registered manager didn't inform the local safeguarding team of an allegations raised against a staff members conduct.”
incident learning
1 finding
moderate“Within some incidents it was not always clear what level of interventions were used due to the way incidents were recorded.”
record keeping
1 finding
moderate“Some incident records were much more detailed than others, quality checks from the registered managers did not always identify this.”
person centred care
1 finding
moderate“People who required a level of observation was spoken about as being 'man-marked' and some incident records were not person centred when describing the incidents.”
care planning
1 finding
moderate“High-level restrictions had not been appropriately assessed in line with the MCA and were not included in people's positive behavioural support plans.”
staff training
1 finding
moderate“Although care staff and managers had received MCA training, we were not assured they always understood the principles of the MCA or recognise restrictive practices.”
other
1 finding
minor“We identified 2 staff files where thorough employment histories had not been recorded.”