critical“The provider had failed to deploy sufficient numbers of suitably qualified, competent, skilled and experienced persons staff to ensure people needs were met regularly, timely and safely.”
missed or late visits
1 finding
critical“Care calls were sometimes late or missed and people were not informed about these changes. This put people at risk of their care needs not being met.”
governance
1 finding
critical“The provider had failed to have effective systems to monitor the quality and safety of the service and mitigate the risks relating to the health.”
incident learning
1 finding
moderate“Lessons learned from accidents incidents and near misses were not always communicated effectively with staff...We saw no records of lessons learnt from this incident.”
record keeping
1 finding
moderate“We identified a number of electronic MAR chart completed without staff signature...The audit failed to identify that MAR charts had not been completed.”
communication with families
1 finding
moderate“People told us communication with the office was poor...They never call me back when they have said they will.”
person centred care
1 finding
moderate“The service did not make reasonable adjustments for people so they could be fully in discussions about how they received support. People received surveys...but the service failed to act on these.”
complaints handling
1 finding
minor“Where feedback received had been negative, we found no action plan recorded to show how it will be resolved. For example, one relative stated 'calls always late.'”