critical“failed to ensure systems and processes were established and operated effectively to assess, monitor and improve the quality and safety of the service”
leadership
1 finding
critical“The registered manager had been absent for some time. There was a lack of clarity as to who was carrying out their role.”
missed or late visits
1 finding
moderate“they sometimes arrive at 10am instead of 9am then they return within 2 hours for the lunchtime call, this means there isn't a four-hour gap for the medicines or for food”
record keeping
1 finding
moderate“relatives we spoke with consistently told us a copy of peoples care plans and risk assessments were not kept in their homes”
incident learning
1 finding
moderate“Accidents and incidents had not been analysed... there was no detailed analysis to pick up and identify any trends or areas to prevent recurrence.”
communication with families
1 finding
moderate“People and relatives told us they were not always happy with the standard of communication with the office based staff.”
care planning
1 finding
moderate“I have asked for a care plan 3 times, I have even emailed requesting the care plan and invoice, I still have not received these.”
medication management
1 finding
minor“one relative told us they were unsure if the medicine was administered at regular intervals as the time of administration was not recorded.”