Updated 19 September 2025
Mental Health Act and Mental Capacity Act Compliance Summary
Staff had completed training in the Mental Capacity Act and consent and Deprivation of Liberty Safeguards (DoLS) and there were policies in place which staff could refer to. Staff demonstrated a good understanding of the Mental Capacity Act and understood that capacity could fluctuate. The provider assumed all clients had capacity and took appropriate action where concerns were raised.
We rated the service as Good.
The service had sufficient staff who were up to date with relevant training and supervision.
Staff assessed client’s needs, developed collaborative care plans with them and supported clients to review their progress during their treatment journey.
Staff provided a range of evidence-based care and treatment which was in line with best practice and national guidance.
Staff were compassionate, respectful and caring and identified and responded to client’s immediate needs.
Managers listened to staff and clients and acted on feedback.
Governance systems were in place which mostly supported managers to monitor and manage the service effectively. Staff felt supported and were proud to work for the service.
However:
Risk management plans were not always robust.
Potential safeguarding concerns were not always explored.
There were some issues with maintenance of the building.
The medicines policy was incomplete and was not robust.
We found 1 breach of regulation in relation to safe care and treatment.
We have asked the provider for an action plan in response to the concerns found at this assessment.