critical“Incident forms recorded staff had on occasions used unplanned and inappropriate restraint for one person. This was a breach of regulation 13 (Safeguarding service users from abuse and improper treatment)”
care planning
1 finding
critical“Plans were not always detailed, up to date or reviewed regularly. Plans referred to 'high' and 'low' level restraint holds without any details of what holds staff should use and when.”
incident learning
1 finding
moderate“Incidents of restraint were not always reviewed in a timely manner to ensure any immediate actions were taken.”
governance
1 finding
critical“The provider had failed to ensure the governance systems fully effective in identify shortfalls and addressing them. Regulation 17 (1) (2) (a)”
record keeping
1 finding
minor“We identified two policies that needed reviewing to ensure they were up to date and reflected current practice and legislation.”
staffing levels
1 finding
moderate“There were some staff vacancies within the service. These were covered by staff picking up additional hours and regular agency staff.”