Note23 Jun 2023
The provider introduced a new quarterly people survey system to better capture service users' views.
Note23 Jun 2023
Staff DBS checks were up to date.
Note23 Jun 2023
The registered manager contacted people and relatives to apologise when things went wrong.
Note23 Jun 2023
The provider worked closely with other agencies including district nurses, families, day centres and the local authority.
Note23 Jun 2023
A time-critical medicines audit supported people to receive medicines at the right time of day.
Note23 Jun 2023
Some evidence of lessons learned following incidents such as medicine errors.
Note23 Jun 2023
People and relatives told us they felt safe using the service; one person said 'I do feel safe with them, they know what they are doing.'
minorsafeguarding23 Jun 2023
Some staff were not always aware of provider whistleblowing procedures.
minorinfection_control23 Jun 2023
People told us some staff did not always wear appropriate person protective equipment (PPE).
minorcommunication_with_families23 Jun 2023
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.
moderateperson_centred_care23 Jun 2023
Issues with staffing pressures and deployment impacted on the service's ability to provide person-centred care.
moderatecare_planning23 Jun 2023
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.
moderaterecord_keeping23 Jun 2023
People's care plans and risk assessments were not updated following changes to people's care and contained outdated information about risks to people.
criticalgovernance23 Jun 2023
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.
criticalgovernance23 Jun 2023
Audits delegated by the registered manager, such as care audits and medicines reviews, failed to identify issues with care records.
moderatestaffing_levels23 Jun 2023
[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.
criticalstaffing_levels23 Jun 2023
'[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.'
criticalincident_learning23 Jun 2023
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.
criticalmedication_management23 Jun 2023
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.
criticalmedication_management23 Jun 2023
People did not have protocols in place for 'as needed' (PRN) medicines and this was not in line with best practice.