moderate“Last Thursday they completely missed a visit and did not turn up at all”
incident learning
1 finding
moderate“There was no formal system to investigate and analyse incidents to look for trends and help prevent reoccurrence.”
governance
1 finding
moderate“There was little analysis of information obtained from audits and monitoring that would allow the registered manager to look for patterns and trend.”
communication with families
1 finding
minor
“We have not been given any information about the service, no booklet or phone number, just the number of a carer but not who to phone in an emergency.”
consent capacity
1 finding
moderate“Some documents had been signed by relatives who did not have authority to do so.”
complaints handling
1 finding
minor“I tried to make a complaint, but the call did not connect to the land line, and it didn't connect to the mobile either.”