minor“We saw two examples where risk assessments were not in place for potential risks. We did not see evidence people had been harmed as a result of this.”
critical“Risk associated with people's care had not always been assessed. This demonstrated that risks in relation to nutrition, falls and pressure care were not being managed to keep people safe.”
safeguarding
1 finding
minor“Some of the staff we spoke with were not aware of where they could report concerns outside of the organisation.”
person centred care
1 finding
minor
“Some people told us the timing of their calls were not always consistent and this was an area they felt could be improved.”
medication management
1 finding
critical“Medication records were not always completed clearly and there were multiple gaps and inconsistencies on the medication administration records (MAR's).”
governance
1 finding
critical“The quality audits for medication, care plans, risk assessments and falls were not effective at identifying issues and gaps in documentation.”
incident learning
1 finding
moderate“Incidents and accidents were recorded but were not reviewed or analysed for patterns or trends. We did not see evidence of any action taken to reduce future accidents.”
staff competency
1 finding
moderate“Competency checks were completed but the documentation to capture information accurately and robustly, and the process for carrying these competency checks out were not suitable.”
record keeping
1 finding
moderate“The service failed to maintain contemporaneous records in respect to people using the service.”