critical“stakeholders provided evidence that at least 35 safeguarding concerns had been made regarding people who use the service...The service had 1 on its safeguarding log.”
medication management
1 finding
critical“MAR had handwritten details that were not signed and counter signed...Where medicines had been altered, stopped or the time of administration changed, there were no notes.”
governance
1 finding
critical“Systems had not been established to assess, monitor, and mitigate risks to the health, safety and welfare of people using the service. Warning notice served.”
incident learning
1 finding
critical“incident log for the service was reviewed and this detailed 4 incidents across a 12 month period. There were additional incidents...none of these were recorded as incidents.”
record keeping
1 finding
critical“Recruitment was not well managed and 8 personnel files reviewed had information missing...Staff files did not consistently have references.”
staff training
1 finding
moderate“staff have not received the required training in this area or other associated training such as mental health awareness, communication tools and positive behaviour support.”
supervision appraisal
1 finding
moderate“Of the 7 staff files reviewed, only one contained documentation regarding supervision...One staff member told us 'no face to face supervisions'.”
missed or late visits
1 finding
moderate“NOK called to complain that carers didn't come last night 06/03/2023 and also carers didn't attend this AM call today 07/03/2023.”
care planning
1 finding
moderate“one person had a diagnosis of dementia and there was a lack of detail about how this affected them in terms of support required or decision making.”
complaints handling
1 finding
moderate“complaints log was reviewed and identified 2 complaints...People spoken with referenced making complaints about the service, but these were not recorded on the log.”
person centred care
1 finding
moderate“one person told us their relative had been put to bed early to meet the needs of the service rather than to support their relatives choice.”
leadership
1 finding
moderate“staff members spoken with told us there was a punitive culture within the organisation, with members of staff being suspended for periods up to 3 weeks without pay.”
communication with families
1 finding
moderate“Communication with the office is bad they don't return calls...carers turned up to do a visit when they had cancelled the call and family were present in the house.”
staffing levels
1 finding
minor“one person had a morning care visit at 10:30-11am, their lunch care visit between 11:10-11:35am and their bedtime visit between 15:05-15:35.”
consent capacity
1 finding
moderate“bar graph regarding MCA training...indicated 92% of the staff team had completed it. 13 staff were spoken with and of these, 2 people had a clear idea regarding what the principles of the MCA were.”
staff competency
1 finding
moderate“staff were emptying catheters and checking them for blockages or twists but had not received training in catheter care.”