moderate“the system showed 1 person had received a medicine twice in 1 day when this was prescribed to have once a day. This meant the person had been overdosed.”
minor“checks to ensure staff were competent to administer medicines following the training had not always been completed.”
consent capacity
2 findings
moderate“for the people who staff told us lacked capacity, records had not been completed to demonstrate their capacity had been assessed and the least restrictive decision had been made.”
critical“staff had hidden the house keys from 1 person in their best interest to prevent them from leaving their home, however, the service had not completed the required paperwork nor had requested an application to the Court of Protection.”
safeguarding
1 finding
moderate“Safeguarding referrals had not always been made following incidents where people had placed themselves at risk of harm to ensure external scrutiny of the service.”
staff training
1 finding
moderate“Staff had not completed training in learning disability and autism. This has been a requirement for all registered health and social care providers since 1 July 2022.”
staffing levels
1 finding
minor“They are only given 10 minutes to drive, we pay them for an hour but the hour we pay them for is only 50 minutes”