moderate“from 7 December 2022 to 28 November 2023, this had not been picked up by the provider; however, the incident had been investigated at the time”
record keeping
1 finding
moderate“staff had used the correct incident identifier for a person whose records stated that they had a scald. action was taken at the time and re-rated to a rash”
missed or late visits
1 finding
minor“A relative told us, 'The staff have other calls to do, so when they finish early, the last 10 minutes could be spent chatting with the person rather than going. Sometimes they rush'”
person centred care
1 finding
minor“One person told us, 'I would feel so much better if it were just one staff member helping me to wash rather than different staff each day.'”
governance
1 finding
minor“Audits were carried out regularly by senior staff to monitor the service provided and assess where improvements were required. However, not all issues were captured through this process.”