minor“Systems and processes for recording the administration of some medicines were not in line with guidance. We shared the good practice guidance with the registered manager.”
complaints handling
1 finding
moderate“Verbal concerns received by the service had not gone through the complaints process which meant they were not resolved.”
communication with families
1 finding
moderate“office management staff and call staff were not always contactable, did not always listen and act on issues in relation to complaining about a small number of care staff”
care planning
1 finding
moderate“The care plan had measures in place for the type of food needed for the person but not how to encourage the person to eat. This meant the person was at risk of not having their nutritional needs met.”
staff competency
1 finding
moderate“temporary staff who provided cover were often not aware of people's needs or had not read their care plan and needed to be reminded by relatives of care needs.”
missed or late visits
1 finding
moderate“one relative who reported a staff member had not always turned up for a call at weekends... it meant a delay to the person being provided with personal care.”
infection control
1 finding
minor“everyone except one relative told us staff wore personal protective equipment (PPE) during the COVID-19 pandemic.”
incident learning
1 finding
minor“one had not been identified in relation to a staff member not supplying food to a person because of the staff member's own religious beliefs.”
governance
1 finding
moderate“surveys were not systematically provided to relatives, which would have identified issues that needed action.”
cultural competency
1 finding
minor“a staff member not supplying food to a person because of the staff member's own religious beliefs.”