moderate“these audits had failed to identify that two people using the agency did not have care plans that contained guidance about all of their health needs”
minor“The format of these sometimes made it difficult to track the progress that was made or when an action had been completed.”
record keeping
2 findings
moderate“for one record that we looked at we saw the circumstances leading up to the incident had not been recorded so it was not clear how or why it had occurred”
minor“Whilst a written analysis of these was not kept to help identify themes and trends the registered manager demonstrated a good awareness of issues that had occurred.”
care planning
2 findings
moderate“one care staff we spoke with did not know a person they had provided care to had diabetes...there was a risk the member of staff might not recognise when the person was unwell”
minor“For one person staff were giving their medication in a specific way but the care plan was not detailed and did not evidence why medication was being administered by this method.”
incident learning
1 finding
moderate“A log was not maintained that identified the number and type of incidents occurring...This meant specific events were not recorded in ways which could highlight trends.”
safeguarding
1 finding
critical“The provider and registered manager had not notified us about some safeguarding events that they were required to by law.”
missed or late visits
1 finding
minor“Detailed records or analysis of late calls were currently not available...call timings were not on the care plan this meant that people may not be clear about the times”
person centred care
1 finding
minor“I do have a problem with continuity of care. I have my primary carer but they keep changing the second one. I find it frustrating.”