moderate“They don't phone to say they are going to be late; the visits seem rushed; they fly in and out.”
moderate“Records showed that staff did not always stay for the duration of people's care calls. There was no audit in place to review staff compliance with care call duration.”
critical“They [staff] are supposed to arrive at 10am but sometimes don't come till 11:30am”
critical“Where one person had a missed call for the planned time of 08:25am they were found later that day to have fallen on the floor and had been on the floor for a number of hours.”
care planning
3 findings
critical
“Risk assessments and associated care plans did not consistently include current and correct information and guidance for staff on risk mitigation.”
critical“People's care plans and risk assessments did not always reflect people's current needs or provide information to staff to manage and mitigate risks to provide safe care.”
moderate“Some of the carers don't read the care plan so they do not know the routine and what is involved.”
medication management
3 findings
critical“Medicines were not always managed safely. For one person who received their medication via a PEG, the medicine protocol for 'as needed' (PRN) medicines did not state that the medicine was to be given via the PEG.”
critical“There was no guidance or protocol in place for staff to follow on administering transdermal patch medicine as per best practice.”
critical“Records showed the time they received their care meant these medicines were given significantly earlier than the prescribed recommendation. This meant there was a risk of harm”
governance
3 findings
critical“Systems and processes were either not in place or not effective in ensuring the safety and quality of the service. The registered manager had not maintained oversight in this area.”
critical“Systems were either not in place or robust enough to demonstrate the safety and quality of the service was effectively managed. This placed people at risk of harm.”
critical“audits were not in place to maintain oversight of accidents and incidents, staff timekeeping, staff supervision or spot checks.”
incident learning
3 findings
critical“3 incident and accident report forms had been completed by staff following acts of aggression or physical violence. This had not prompted the provider or registered manager to update the risk assessments.”
moderate“Trends and patterns were not always identified to improve safety across the service. There had been a number of incidents involving people's catheter care.”
moderate“The records had not always been reviewed for any remedial actions required or lessons learned.”
record keeping
3 findings
moderate“Care records contained high levels of generic information or outdated guidance which in some cases posed a risk to people, including choking and pressure sore deterioration risks.”
moderate“Missing information in people's care and support plans. This included information on mental capacity and pressure care support.”
moderate“Staff files were found to be missing full work history as per the regulatory requirement.”
staff competency
2 findings
moderate“The training and competency checks were not of a standard to ensure staff had the knowledge and skills to carry out their roles effectively.”
moderate“We identified one person who's needs could not fully be met due to staff not having the right skills and experience and family had continued to support where required.”
leadership
2 findings
critical“The provider had not implemented an action plan to address the shortfalls identified at the last inspection to ensure they would be compliant in meeting the regulatory requirements.”
critical“The registered manager had not fully understood the regulatory requirements. For example, there had been three significant events which the Care Quality Commission (CQC) had not been notified of.”
supervision appraisal
2 findings
moderate“Senior members of staff who were responsible for auditing and updating people's care records needed further support and training in this role.”
moderate“Records showed inconsistency in the frequency of staff supervision.”
consent capacity
2 findings
critical“Mental capacity assessments were not always completed for decisions relating to people's care or treatment.”
moderate“Some family members had signed on behalf of their relative on some records... We recommend that where people have the capacity to consent, their consent and agreement is clearly recorded.”
infection control
2 findings
moderate“We could not be assured that all staff followed current COVID-19 Government guidance. We observed staff supporting a person in their home without wearing a face mask.”
moderate“We found a small number of staff had not attended testing but had continued to work. This meant people had been exposed to increased risk of infection.”
communication with families
2 findings
minor“One person told us, 'I did phone up and [staff] snapped my head off so I hung up. I avoid ringing them.'”
minor“Communication with the office is not always good and they don't always reply to their emails and I find it annoying that some of the office staff don't understand me.”
person centred care
1 finding
moderate“Some people's preference around visit times and preferred staff was not always met. One person told us 'I'm not really happy with the management as there is no continuity of carers.'”
staffing levels
1 finding
moderate“Staff travel time between calls was very limited and set at five minutes for all calls. This did not account for busier times of the day for traffic”
staff training
1 finding
moderate“Specialist training for people's individualised needs such as, people with Parkinson's, catheter/convene care needs or percutaneous endoscopic gastrostomy (PEG) feeds was inconsistent.”
complaints handling
1 finding
minor“a brief overview of each complaint was not included to monitor for trends and patterns and support improving the quality of the service.”