critical“Risk assessments and the related moving and handling care plans did not contain the sling size, when the hoist was last serviced, hoist type, or what checks needed to be completed.”
incident learning
1 finding
critical“Staff could not remember having any discussions in relation to lessons learnt following recent incidents of falls. We did not see any evidence to support how any lessons learnt were effectively cascaded.”
governance
1 finding
critical“The provider did not have effective systems and processes to identify where quality was compromised and to respond appropriately and without delay.”
staff competency
1 finding
moderate“Two out of six records we reviewed showed that these competencies were not completed properly to ensure staff had been assessed on various aspects of moving and handling and medicines administration.”
communication with families
1 finding
minor“One person was registered blind but the care plan instructed staff to show their ID badge to the person on arrival. The care plan was also not available in a format that was understood by the person.”
missed or late visits
1 finding
moderate“We reviewed an incident log of January 2022 and noted there was one missed visit and 48 late visits... the same conclusion for subsequent months.”