minor“One person's care plan indicated they had a pressure sore... this person did not have a pressure sore and this was incorrectly documented in the care plan.”
moderate“People who were diabetic had a diabetes fact sheet in their care plan... However, person specific diabetes risk assessments were not in place.”
leadership
1 finding
moderate“There had been a lack of consistent management which led to instability over the last year.”
governance
1 finding
moderate“These checks did not identify the issues we found with regards to diabetes risk assessments and a care plan not including up to date information.”
communication with families
1 finding
moderate“The majority of people and relatives we spoke with told us that they did not know who the registered manager was.”
missed or late visits
1 finding
minor“Sometimes they are a bit late. Last week they did call a couple of times to say they were delayed.”
incident learning
1 finding
minor“There was a lack of information about lessons to be learnt following an incident/accident.”
staff competency
1 finding
minor“They have all been trained but some are more competent than others.”