moderate“Staff had not recorded checking water temperature for one person or skin pressure damage checks for three people.”
minor“Staff rotas were not always effective in accurately planning people's care. One person's morning call was scheduled for 10:00 but was consistently taking place around 06:00.”
governance
2 findings
moderate“Audits completed had not identified concerns found on inspection. Audits were not completed on call times.”
minor“There was no section within the staff meeting records to show what issues staff had raised and who was responsible for addressing and resolving these issues and by when.”
care planning
1 finding
critical“Not all people had detailed risk assessments in place. For example, risk assessments which did not contain all the potential and known risks for one person who smoked and used emollient creams”
missed or late visits
1 finding
moderate“Due to staff being late I don't always have my tablets at the right times. Sometimes they don't have time to do you a dinner, so it has to be something quick.”
medication management
1 finding
critical“Staff did not record the reason for administering a medicine prescribed on an 'as required basis' to manage a person's distress or pain.”
complaints handling
1 finding
moderate“One relative told us their recent complaint had not been dealt with to their satisfaction and communication with management had been lacking. This complaint was not documented on the complaints log.”