moderate“The incidents were not always analysed to identify actions which could reduce further risks. For example, the record for 1 incident identified that a person had experienced a fall when trying to let the staff member into their home. There was no guidance for staff on how the risk”
complaints handling
1 finding
minor“The provider had not undertaken a review of the complaint to identify possible lessons which could be learnt from the issues raised. This meant the provider did not identify what longer term actions or changes to systems could be taken to prevent the issues from the complaint occ”
care planning
1 finding
moderate“Where a person had been identified as living with a medical condition such as neurological illnesses or diabetes there was not always enough detail for staff on the condition.”
medication management
1 finding
moderate“The risk assessment did not identify medicines the person had been prescribed which were not administered by staff...the risk assessment did not list all the medicines prescribed which included a medicine to thin the person's blood.”