moderate“"Timekeeping is very poor particularly in the morning". One relative noted if the carer worker was not coming, the provider did not tell them in advance.”
governance
1 finding
critical“Monitoring systems were not being used effectively to monitor and mitigate risks to the health, safety and welfare of people using the service.”
medication management
1 finding
moderate“The provider administered a prescribed emollient cream to one person but did not record this on a Topical Medicines Application Record (TMAR).”
incident learning
1 finding
critical“As there was no investigation of the concerns raised, there had been no opportunity to learn lessons and help mitigate the same thing happening in the future.”
record keeping
1 finding
moderate“Audits of people's files had not identified staff were not recording the administration of a prescribed cream or risk assessed how flammable the cream was.”
communication with families
1 finding
minor“"If there is a problem like the carer not coming, they don't say in advance. I have told the office, but they are not responding to that."”