moderate“Two relatives said this was not the case and calls would often be short of the agreed time.”
minor“at weekends staff were sometimes late, though usually there was a call explaining why staff were going to be late.”
critical“People did not always receive their care and support at their planned call times. People experienced inconsistent call times from care staff which impacted upon their well-being.”
complaints handling
3 findings
moderate“Complaints made earlier in the year did not have evidence of any outcomes. The regional manager said the written response from the previous registered manager could not be found.”
moderate
“Systems were not being operated to manage, respond to and resolve people's complaints. We saw numerous examples of people having contacted the office to make complaints however, these were not recorded.”
moderate“office staff had not always used the correct code to identify complaints which meant that complaints had not been escalated to the provider or senior staff to respond to formally.”
record keeping
3 findings
minor“records supplied recorded this was the case, they did not show if people had been asked if they were in agreement for staff to leave.”
critical“Staff had not recorded in the daily notes that they had administered the medicines to people and no-one could be sure if people had received their prescribed medicines.”
minor“Staff confirmed that although care plans were not up to date they knew what support each person needed and they worked well together sharing information.”
leadership
3 findings
moderate“The service did not have a registered manager in place as the previous registered manager had resigned just before the inspection.”
critical“There was a systematic failure in the leadership and governance of the service which had resulted in safe systems of care failing to be implemented consistently.”
critical“There was not a registered manager in post although a new manager had recently been appointed who told us that they would apply to become the registered manager.”
safeguarding
2 findings
critical“Staff had failed to recognise incidents which should be reported to the safeguarding team, investigate incidents or to take appropriate action to mitigate the risks to people.”
critical“three investigations had been allocated to the previous acting manager however; there was no evidence of these investigations having been completed.”
staff training
2 findings
critical“Staff were not required to refresh or update their training. There was no requirement for this training to be updated or refreshed.”
moderate“Other staff told us that the moving and handling training was not detailed enough because old equipment was used which led to confusion when they were caring for people.”
supervision appraisal
2 findings
critical“A number of staff had not had a formal supervision in over two years. When staff had received supervision this was not consistently completed appropriately.”
moderate“Another care staff said 'I have done some specific training and I am waiting for a competency assessment but no-body has done it with me yet, I've been waiting for months.'”
care planning
2 findings
critical“People's plans of care had not been reviewed in over 12 months and for a number of people their plans of care were not reflective of their current care and support needs.”
moderate“The majority of staff told us that information in care plans and on the summary sheets were not up to date and the information was not accurate.”
governance
2 findings
critical“There was a systematic failure to implement any of the provider's procedures for quality monitoring. The provider had not completed any audits of care plans, medicines or people's call times.”
critical“Effective quality assurance procedures had not been implemented which had resulted in shortfalls failing to be recognised or acted upon appropriately.”
person centred care
2 findings
moderate“Staff were focussed upon the task of delivering care rather than delivering care in a person centred manner according to people's individual preferences.”
moderate“staff did not understand the expectations placed upon them in relation to people's call times which resulted in them feeling under pressure and rushed.”
incident learning
2 findings
critical“Where people had contacted the office to report medicines errors the provider had not taken sufficient action to prevent these from occurring again in the future.”
moderate“a box of audits had been found in the office after the manager had left however, no action had been taken as a result of the audits that had been completed.”
medication management
1 finding
critical“We reviewed the MAR charts for 12 people and found that each of these charts had omissions in the recording of what medicines had been administered. We found gaps for critical medicines such as Morphine and medicines for Parkinson Disease.”
staffing levels
1 finding
critical“The care and support for over 200 people was being coordinated by three people including the manager. This resource was not sufficient to safely coordinate people's care and support.”
infection control
1 finding
minor“Staff told us that they were not always informed when a person was displaying symptoms or waiting for a COVID-19 test result.”
staff competency
1 finding
moderate“Another care staff said that they had not been shown one piece of equipment at all and 'no idea how to use it when I was at the person's house.'”