critical“People did not have protocols in place for 'as needed' (PRN) medicines and this was not in line with best practice.”
critical“Staff had recorded this patch had been changed on medicine administration records (MARs), but then recorded in care notes that this patch would be changed at a later care call.”
staffing levels
2 findings
critical“'[Sagecare] say to me We've got nobody to come at a weekend... [my other support] can't do personal care or my pills and that's what I need.'”
moderate“[Sagecare] are changing 40-minute care calls into 20-minute care calls or no care call at all. The poor carer doesn't know what's going on.”
governance
2 findings
critical“Audits delegated by the registered manager, such as care audits and medicines reviews, failed to identify issues with care records.”
critical“Provider systems were ineffective in driving improvement to enable them to achieve a good rating. This was the fourth consecutive inspection where the service was rated requires improvement.”
incident learning
1 finding
critical“Despite this known risk, there was no information to inform staff to encourage this person to use their lap belt to reduce the risk of re-occurrence.”
record keeping
1 finding
moderate“People's care plans and risk assessments were not updated following changes to people's care and contained outdated information about risks to people.”
care planning
1 finding
moderate“Staff failed to document relevant information to help manage risk... staff had recorded on several occasions that this had been completed by others, with no further information.”
person centred care
1 finding
moderate“Issues with staffing pressures and deployment impacted on the service's ability to provide person-centred care.”
communication with families
1 finding
minor“I don't mind if the time varies, but they need to tell me. Mostly they don't, and I have to ring up to find out.”
infection control
1 finding
minor“People told us some staff did not always wear appropriate person protective equipment (PPE).”
safeguarding
1 finding
minor“Some staff were not always aware of provider whistleblowing procedures.”