critical“Staff including management did not fully recognise a particular practice was a form of restraint. They had not ensured this practice was in the person's best interests and the least restrictive option.”
consent capacity
1 finding
critical“There was no evidence the capacity of the person had been fully assessed to determine what decisions they could and could not make for themselves.”
care planning
1 finding
moderate“The person's care plan did not consider their cultural needs or their sexual identity. This meant staff could not be sure they were supporting the person as they would wish.”
governance
1 finding
critical“Governance systems were not robust and had failed to monitor and improve the quality and safety of the service provided. This placed people at risk of harm.”
record keeping
1 finding
moderate“We found several examples of information which was out of date in the person's care plan. For example, the care plan stated the person disliked vegetables, but this was not the case.”
staff training
1 finding
critical“One staff member told us they had only completed one shift shadowing an experienced staff member before working alone with the person receiving support.”
incident learning
1 finding
moderate“Although staff raised concerns and recorded incidents when things went wrong, the learning from incidents was not always shared with the wider staff team.”
person centred care
1 finding
moderate“There was no evidence of how the person had contributed to the development of their care plan.”
communication with families
1 finding
moderate“A key individual in the person's life told us they had not been invited to participate in reviews of the person's care.”
infection control
1 finding
minor“There was no risk assessment completed to identify the risks posed by this decision [staff not wearing masks] and how they could be reduced.”