moderate“Risks to people's health and wellbeing were not always assessed and documented. This meant key information about how to mitigate these risks was not always available to staff.”
moderate“Care plans for people with diabetes were not person-centred...didn't inform staff of each person's individual needs. This increased the risk of people's diabetes not being managed correctly.”
medication management
2 findings
moderate“Protocols were not always in place to guide staff about when to administer 'as and when required' (PRN) medications...posed an increased risk that medicines could be administered incorrectly.”
minor“One medication had not been administered and staff had not used the code on the MAR chart to record the reason for this.”
record keeping
2 findings
moderate“Care plans did not always contain details to guide staff about people's health needs...care plans were not in place to inform about people who took medicine that thinned their blood.”
moderate“care plans did not always detail people's health care needs...risk assessments for using the hoist lacked some essential details”
governance
2 findings
moderate“Governance systems had not been effective in ensuring risks to people had been robustly assessed, documented and mitigated. This put people at risk of potential harm.”
moderate“these audits had failed to identify that in some instances care records needed to be improved...one medication record failed to record why medication had not been administered”
safeguarding
1 finding
critical“The registered managers had not notified us about some safeguarding events that they were required to.”
incident learning
1 finding
moderate“no effective system in place to analyse trends and patterns to enable lessons to be learnt...Incidents, including late calls were recorded in several different places”
communication with families
1 finding
minor“they were not always informed when staff were going to be late or if a different staff was coming. One relative told us, 'When there's a new carer, you don't always know they're coming.'”
complaints handling
1 finding
minor“the complaints procedure lacked details of all of the agencies people could contact if they remained unsatisfied with the provider's investigation”