critical“49 care workers had at least one visit which started outside of the one-hour window which was 17% of all visits that week.”
critical“120 care visits had been scheduled for 31 care workers which overlapped a visit for another person... visits occurring over one hour later or earlier than planned.”
consent capacity
2 findings
critical“The provider's processes in relation to assessing a person's capacity to make decisions about their care did not always follow the principles of the MCA.”
critical“The provider did not always undertake mental capacity assessments where people might not have the capacity to consent to their care, in line with the MCA.”
complaints handling
2 findings
critical“The provider did not always consider the issue of the complaint as part of their investigation which meant the investigation was not always effective at identifying preventative measures.”
moderate“Complaints records showed that outcomes following complaints investigations and measures to prevent similar concerns were not always identified.”
governance
2 findings
critical“The provider did not have effective and robust quality assurance processes to monitor, assess and improve the quality of services people received.”
critical“The provider carried out an audit of MAR charts... The audits were not robust enough as they indicated there were no issues, but we found a range of concerns.”
incident learning
2 findings
moderate“The provider could not demonstrate that they had investigated the concern, analysed the cause and identified the actions required to prevent a similar concern.”
critical“Records for three safeguarding concerns were reviewed and we saw that there was limited information recorded about what happened with no lessons identified.”
staffing levels
2 findings
critical“The provider did not ensure sufficient suitably qualified, competent, skilled and experienced staff were deployed to meet people's support needs.”
critical“46 care visits had been allocated to 23 care workers without travel time for the next visit so one visit ended at the same time the next visit started.”
care planning
2 findings
moderate“There was no risk management plan for when the person was supported to take part in activities outside of their home.”
critical“Care plans were not written in a person-centred manner which identified the person's wishes in relation to how they wanted their care provided.”
record keeping
2 findings
moderate“The audits for the May 2022 included the same issues that were identified in the April 2022... the reason for these errors was not identified so preventative measures could be taken.”
moderate“The provider informed us they supported eight people with their medicines, but the local authority confirmed that at the time of the inspection there were 22 people being supported.”
medication management
1 finding
critical“The provider did not have a PRN protocol in place to provide care workers with guidance on when they should administer these medicines.”
staff training
1 finding
critical“The provider could not demonstrate the care workers had completed the additional 12 training courses they identified as mandatory which included safeguarding adults and health and safety.”
person centred care
1 finding
moderate“The daily records of care provided during each visit were task focused and did not reflect the experiences of the person receiving support.”
end of life care
1 finding
moderate“People's wishes in relation to their end of life care were not recorded as part of their care plan.”
communication with families
1 finding
moderate“The care plan for one person indicated they lived with a hearing impairment and used lipreading... The person's care plan had not been updated to provide care workers with guidance.”