critical“Systems and processes in place to assess and monitor the service were not consistently effective at driving and maintaining improvements.”
missed or late visits
1 finding
moderate“feedback from people and relatives identified the issues remained around staff being late and people not being informed.”
staffing levels
1 finding
moderate“I have told them [the provider] keep the same carers but I get different carers. They change like the weather.”
medication management
1 finding
moderate“one person had not always received their medicines at a consistent time. For example, every four hours... medication had been administered between a four and six hour window.”
care planning
1 finding
critical“Two people with a medical condition of epilepsy did not have a separate protocol in place to provide staff with information on what action to take”
communication with families
1 finding
moderate“only one of the 13 people and relatives we spoke with said they received a call to let them know when staff were running late.”
complaints handling
1 finding
moderate“I've given up phoning the office as no-one gets back to you.”
cultural competency
1 finding
moderate“[Person] cannot speak or read English. There was no discussion on having a care plan in Punjabi.”
infection control
1 finding
minor“One staff member had been wearing their own clothes rather than their uniform and some staff had disposed of their used personal protective equipment (PPE) in people's own rubbish bins.”
incident learning
1 finding
moderate“The records did not always show what had been put in place to mitigate reoccurrence or identify potential trends.”
staff competency
1 finding
minor“I have to explain to new carers what to do.”
record keeping
1 finding
moderate“care records and risk assessments... still required more detail to ensure information was clear and up to date for staff to refer to.”