critical“People's care visits were not always organised to ensure medicines were administered with sufficient gaps between the doses.”
critical“Best practice guidance was not always followed. This included guidance to support the safe use of topical medicines, such as creams, gels and patches.”
critical“Information on people's GP medicines lists did not always match with the provider's electronic medication administration records”
missed or late visits
3 findings
critical“The times are all over the place, [person] is constantly ringing to find out when the carers are coming.”
moderate
“For only 2 out of 28 visits care staff stayed for the full length of the care visit that the person was commissioned to receive.”
critical“People often received care visits either early, late or in some instances the care visit was missed.”
governance
3 findings
critical“Systems had not been established to robustly assess, monitor and improve the quality of the service. This placed people at risk of harm.”
critical“The provider's quality assurance system had not identified issues we found on inspection, including with safeguarding, risks to people, medicines, staff competencies, care records.”
critical“There were significant and widespread shortfalls in the governance of the service, placing people at risk of harm.”
record keeping
3 findings
moderate“Medicines records did not contain details of the quantity of topical medicines, such as creams, that should be applied.”
moderate“Full information about risks to people's safety was not always identified in people's care records to alert staff and guide them in how to reduce the risk.”
moderate“The provider did not always keep records where people had lasting power of attorney in place”
care planning
3 findings
minor“People's care plans did not always show people had the opportunity to discuss any preferences or wishes for their care in the future, including end of life care.”
moderate“Care plans and risk assessments did not always contain information on risks linked to people's health needs, such as catheter care.”
critical“Care plans and daily care records contained standardised information with limited evidence of person-centred care.”
person centred care
3 findings
minor“A small number of people and their relatives told us their preferences for female care staff were not always being met.”
moderate“People's preferences for female care workers were not always considered or recorded in their care records.”
critical“Care was organised by the provider in a way that was task-centred and was not always person-centred.”
staffing levels
2 findings
moderate“Some staff worked across large geographical areas, which presented challenges to providing people with a consistent and reliable service.”
critical“the provider had failed to ensure there were sufficient staff to meet people's needs.”
safeguarding
2 findings
critical“People were not always protected against the risk of abuse. On occasions, people were subjected to neglect by care staff, causing people distress and discomfort.”
critical“safeguarding concerns were not being raised by the provider in-line with local arrangements.”
staff competency
2 findings
critical“Care workers carried out specialist care tasks for which they had not always had their competence assessed to ensure they were safe.”
critical“Competence checks were not carried out to assess staff knowledge and skills in areas such as moving and handling and medicines.”
end of life care
2 findings
moderate“End of life care plans were not always in place for people receiving end of life support. We were not assured staff would have sufficient information to guide them.”
critical“The provider was not well prepared for caring for people needing end of life care.”
incident learning
2 findings
critical“Lessons were not always being learnt to prevent further safeguarding allegations. The provider sent a care worker to a person following previous allegations about the same care worker.”
critical“It was not clear lessons were learnt following safeguarding concerns to prevent reoccurrences and keep people safe.”
leadership
1 finding
critical“Roles, responsibilities and accountability were not clear within the provider's management and staffing structure.”
staff training
1 finding
critical“It was not clear if staff had received training in areas such as safeguarding, end of life care, first aid or mental capacity.”
supervision appraisal
1 finding
critical“The provider had not followed their supervision policy and 62% staff had not received supervision in the last 12 months.”
complaints handling
1 finding
critical“the provider had failed to investigate and take action in response to a complaint and have effective systems for handling and responding to complaints.”
infection control
1 finding
critical“People were not always protected from the risk of infection due to inconsistent infection prevention and control practice by care staff.”
consent capacity
1 finding
critical“It was not clear whether people's capacity to consent to their care arrangements was assessed by the provider.”
communication with families
1 finding
moderate“People, relatives and staff all reported instances where they had not been able to make contact with the office.”
cultural competency
1 finding
moderate“People's diverse needs were not always considered or well recorded.”