critical“Care plans for people who had sustained pressure damage did not provide information from the district nursing team, such as, the stage of their sore.”
governance
1 finding
critical“All audits were completed on the first day of each month and findings were copied over each month word for word.”
incident learning
1 finding
critical“The management did not collate all falls and injuries to see if there were any emerging trends and patterns to address.”
safeguarding
1 finding
critical
“Unexplained bruises to people had not always been investigated to establish whether a safeguarding referral to the local authority or further medical involvement was required.”
infection control
1 finding
moderate“They are leaving used personal protective equipment (PPE) all over the house. Clothing dropped and left on the floor.”
complaints handling
1 finding
moderate“Not all complaints had been recorded in accordance with the provider's policy... the registered manager was unable to establish any emerging trends and patterns.”
record keeping
1 finding
moderate“People's communication needs were not always included in their care records. Some people were unable to use words to communicate... This information had not been included in the people's care plans.”
supervision appraisal
1 finding
moderate“Supervision forms prompted the supervisor to ask questions and undertake observations, these were not always completed.”
staff competency
1 finding
moderate“The registered manager was unable to provide evidence of additional training to equip office staff to complete these duties.”
missed or late visits
1 finding
minor“Missed and late visit logs showed some visits were consistently cut short. Where this may have been the person's choice, there was no documented analysis carried out.”
person centred care
1 finding
moderate“some people had mentioned that there had at times been a lack of flexibility regarding changes to care packages. There were instances when people had requested changes, but this had been dismissed”
end of life care
1 finding
minor“People were not always asked about their wishes and preferences at the end of their lives. This is an area for improvement.”