critical“we could not be assured people consistently received support from two care staff where this need was identified... only one staff member attended the call”
critical“People's care was not provided for the amount of time commissioned in order to meet their needs. Visits were consistently shorter than the scheduled call.”
staffing levels
2 findings
critical“Some calls with two staff lasted as little as 9 minutes and should have been 30 minutes.”
critical“There were not enough staff deployed to consistently meet people's needs. The provider told us they were short staffed as it was difficult to recruit.”
governance
2 findings
critical“the provider had not identified the concerns we found during this inspection... no effective systems in place to oversee staff allocation”
critical“the monthly audit had not been completed for the 'last few months, as we been so busy.' We asked for a copy of any previous audit for the last twelve months, but none could be found.”
safeguarding
2 findings
critical“we identified one issue which the provider had not identified to be a safeguarding concern... not notified the commission of all the safeguarding alerts”
moderate“The safeguarding policy was not specific to the service and did not include basic information such as the name and contact details of the multi-agency safeguarding team.”
record keeping
2 findings
moderate“Records showed people did not always get the visits as they were commissioned by the funding authority and which they were assessed as needing.”
moderate“Some staff continued to log in and out of visits a distance away from the person's home, up to 4km which meant there was not an accurate record of when they arrived and left.”
staff competency
2 findings
moderate“they would engage the assistance of a family member. The provider could not evidence the family member was suitably trained and competent.”
moderate“staff were unable to demonstrate a robust system for assessing their competency [in medicines]. The provider had not followed national guidance which requires a formal assessment.”
medication management
2 findings
critical“There were gaps in Medication Administration Records (MAR). This meant people may not have received their medicines as prescribed.”
critical“four staff had signed the records and had not received the training [for PRN medicine requiring specialist training].”
care planning
1 finding
moderate“for one person the risk assessment had not been updated to show their care needs had changed and they needed the support of two staff”
missed or late visits
1 finding
critical“one person was commissioned for four calls per day, we reviewed their call log for thirteen days, which showed a total of three calls were for the full time.”
staff training
1 finding
moderate“New staff had not completed safeguarding training. New staff had not received training for moving and handling before they started to support people.”
leadership
1 finding
moderate“There was a lack of clarity about management roles. There was not a clear leadership structure and staff roles were not clearly defined. 'We are so short staffed our jobs have all merged. We're fire-fighting.'”
incident learning
1 finding
moderate“There was not a systematic approach to ensure learning was carried forward into practice. There was not a formal system to monitor, identify and respond to feedback, concerns and trends.”
infection control
1 finding
moderate“The provider confirmed staff had not been routinely testing twice a week... staff were wearing masks but not changing them for each new person they supported.”
communication with families
1 finding
minor“They don't always let me know if they are late. Last time they were really late there was actually nobody in the office to call about it.”