moderate“the audit had not identified that your electronic system had not generated a medicine administration record.”
critical“Due to a missed care call, one person did not receive their medication as prescribed. Another person did not receive their medication because this was 'forgotten' by a staff member.”
governance
2 findings
moderate“some audits were a tick box exercise rather than demonstrating exactly what was checked.”
critical“The provider did not have an effective care call monitoring system and people had experienced missed calls... their current system did not create an alert when staff failed to arrive at a care call.”
record keeping
2 findings
moderate“there was no record of whose care plan and what had been checked, to ensure actions were taken when required.”
moderate“the medication audit showed no evidence of people's medication administration record being checked. The audit focused on what would be relevant in a care home.”
missed or late visits
1 finding
critical“People had experienced missed care calls... This included a missed mealtime call to a person who could not access their own food and drink. Another person had a missed care call when medication was due”
safeguarding
1 finding
critical“they had not recognised neglect as a potential form of abuse or a safeguarding concern... seven incidents that should have been reported to us. These included five incidents of neglect”
person centred care
1 finding
moderate“We stated a gender preference for staff, but this is not met and my relation has no dignity or modesty, it is heart-breaking.”
staff training
1 finding
moderate“I did an online theory session on moving and handling but nothing on using equipment... I would have felt more confident and safer using it if I had been showed and trained before using it”
complaints handling
1 finding
moderate“some relatives made us aware of issues they had verbally complained to the compliance manager about, but we found no written record of the concern or complaint”
incident learning
1 finding
moderate“for two incidents, there was no written staff record of the actions proposed for improvement having been followed through.”
staffing levels
1 finding
moderate“I have three care jobs and work 60 hours a week... the registered manager had not asked staff to inform them when they had multiple jobs”
infection control
1 finding
minor“part of the infection control policy referred to 'the home' (care home)... This policy had not been adapted by the registered manager to the needs of their staff.”
leadership
1 finding
moderate“Leaders and the culture they created did not always promote high-quality, person-centred care.”