critical“The provider had failed to ensure they had enough suitably trained staff to deliver care as planned. This was a breach of regulation 18 of the Health and Social Care Act 2008.”
missed or late visits
1 finding
critical“The carers are never on time, they can be late or early. I've had numerous meetings with the agency about it. They say they can't do anything about it as they are understaffed.”
person centred care
1 finding
critical“The provider failed to ensure care was planned and delivered in a personalised way. This was a breach of regulation 9 of the Health and Social Care Act 2008.”
governance
1 finding
critical“The provider failed to ensure they had effective quality monitoring measures in place, failed to act on feedback received and failed to ensure they kept complete and contemporaneous records.”
medication management
1 finding
moderate“People who were prescribed medicines which were time specific or required a set amount of time between doses were not always supported to take these as prescribed.”
care planning
1 finding
moderate“Care records were not always kept up to date to reflect people's current choices and requirements. I've sent concern reports in regarding changes that need to be amended on individual's care plans which don't get actioned.”
record keeping
1 finding
moderate“Records we checked contained out of date information regarding people's medicines. Staff were not guided by the provider to record all types of medicine support.”
supervision appraisal
1 finding
moderate“Staff told us they did not have regular supervisions and there were inconsistencies in the support they received from management.”
complaints handling
1 finding
moderate“If I try to ring the office I can't get to speak to the manager and if I email the office I get no reply. I have complained about timings of visits – they are never on time – but nothing improves.”
communication with families
1 finding
moderate“We have no contact from the office, I phoned them once and they never called me back, so I don't bother now.”
staff training
1 finding
minor“Without in-person training I felt somewhat unprepared when I first started.”
incident learning
1 finding
minor“Staff told us they were not made aware of outcomes from concerns they had raised; therefore, we cannot be confident lessons were shared amongst the staff team.”
end of life care
1 finding
minor“The provider had an 'end of life' policy in place which was well written, but in the records, we checked we found no evidence of the advised care planning around end of life having been put into practice.”