minor“I have a window of time and the care workers do not always arrive between those times. On occasion it has been as late as 11.30.”
moderate“'Timing is erratic. They should be here at 9:am and it has been as late as midday'”
moderate“56% of calls were less than half the planned duration. There were 608 pairs of calls where staff had logged in at 2 locations simultaneously”
medication management
2 findings
critical“gaps identified on the MAR chart. The registered manager was unable to clarify why there were gaps.”
critical
“A mediation audit was completed however, this was not robust or completed regularly which meant the registered manager did not have clear oversight”
record keeping
1 finding
minor“We found on 1 person's recruitment file a full employment history had not been obtained. The HR manager took immediate action and contacted the staff member.”
governance
1 finding
critical“effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17”
incident learning
1 finding
minor“lessons learnt contained limited information and lacked detail. Actions taken did not include any dates and details of who needed to complete the actions.”
communication with families
1 finding
moderate“'I have never met her or spoken to [manager]. I have spoken to [office staff] but they get very defensive'”