minor“there were gaps where the blinds were not properly secured. This meant there was a potential risk of someone accessing sight of documents they were not authorised to view.”
minor“minutes for a recent meeting merely noted, 'Mobile phones' or 'Meds and Mar charts.' There was no other notes made available.”
minor“when recording the amount of fluids a person consumed they had not referenced the quantities.”
infection control
1 finding
moderate“We were not assured that the provider was meeting shielding and social distancing rules...staff did not always adhere to social distancing in the office environment.”
staff training
1 finding
minor“some areas of training, such as moving and handling and safe administration of medication, were not appropriate to be delivered by remote means”
missed or late visits
1 finding
critical“staff did not arrive to provide care to one person on a Saturday yet this was not discovered until the following Monday.”
governance
1 finding
moderate“reviewing of incidents, accidents, complaints and call times was not an area that was responsive or that considered emerging patterns, themes or trends.”
consent capacity
1 finding
moderate“one person had only an LPA in place for financial matters, when the decisions made were health related, which meant the appropriate consents were not in place.”