critical“Positive behaviour support plans for 1 person did not include all the actions taken by staff as part of a de-escalation technique.”
record keeping
1 finding
critical“There were occasions where this person was being locked in their room...This was not included in the plan...this lacked the detail required for decision-making.”
consent capacity
1 finding
critical“The people at the service had not been reassessed and there was no involvement from the Court of Protection.”
governance
1 finding
moderate“We found this document did not include the restriction around locking someone in their room.”
incident learning
1 finding
moderate“For one person the registered manager referred to the actions of staff being in line with a person's care plan however...this was not clearly outlined.”