Liam Kenyon

The_MATTERS QF CONCERN are as follows: May Bury they may they

The evidence highlighted a lack of clarity as to the extent of the care provided by the supported housing association and how staff interpret this. The Court was informed that the housing association have a duty of care to its residents" and that this included " safeguarding residents" and the "risk management of residents" . However when the situation arose on the 17ih July 2020 the Court was advised the housing association are not care providers and should not have become involved in the plan to monitor Liam: Having agreed with the support plan and this being confirmed in an email to staff, hourly checks were not conducted on Liam_ 3_ The Court heard following the incident on the 17ih July the procedure of asking Liam if a drug check of his room could be conducted was not done In addition following him being found unconscious due to a suspected overdose the Court heard his risk assessment should have been updated and this was not done.
5. The Court heard that on the 18th July a staff member went to Liams room on three occasions (from 1Oam) and knocked on the door receiving no response_ The Court heard that where no response was received a physical welfare check involving 2 members of staff entering the room using the master key should have occurred: The Court heard that at a weekend there are less staff to cover all the sites and on the 18th July the staff were dealing with a number of incidents involving residents; meaning to conduct hourly checks would have been difficult However no member of staff escalated to the on call manager the fact that there were problems. Finally the Serious Incident Review process which is in place to learn lessons from such incidents was deficient and ineffective.