critical“The provider had not always ensured people were protected from unlawful deprivations on their liberty.”
consent capacity
1 finding
critical“The provider was not always working in line with the MCA. People's capacity to make decisions was not always assessed. Decisions were made for people without lawful authority.”
staff training
1 finding
critical“We found some staff had not completed training in learning disability awareness, autism and mental capacity and were supporting people with these needs.”
staff competency
1 finding
critical“Where staff had not passed the competency assessment at the end of the training course, they continued to support people without supervision.”
governance
1 finding
critical“The provider had not always ensured there were systems and processes to assess, monitor and improve the quality and safety of the service.”
incident learning
1 finding
moderate“There was no formal review of incidents and no actions recorded to demonstrate the provider had done all they could to reduce risks in future.”
care planning
1 finding
moderate“The provider had not always ensured that people's care records contained clear guidance for staff about how to support people effectively.”
medication management
1 finding
moderate“when people took medicines on an as and when basis (PRN) there were not always protocols to guide staff as to how to recognise when these may be required.”
person centred care
1 finding
moderate“people's dignity was not always promoted when people displayed behaviours that were normal for them.”
record keeping
1 finding
moderate“staff, the registered manager and company director had documented a person's behaviours and their response to these in an undignified way.”
leadership
1 finding
moderate“the registered manager had not recognised the requirement for applications to the court of protection, mental capacity assessments or best interest decision records.”