moderate“From 01 September 2022 to 22 September, people's care visits were not delivered at the time they were scheduled.”
moderate“The majority of their morning calls were carried out between 7am and 8am instead of 8am and 9am. The majority of their lunch time calls were between 11am and 12pm instead of 12pm to 1pm.”
critical“Clients have been left without calls or their medication.”
critical“The timesheets for one person demonstrated 36 occasions over a 47 day period whereby staff did not stay for the required time they should.”
governance
2 findings
critical
“We were not assured the current governance arrangements were robust enough and effective in identifying or taking action with regard to staffing shortfalls and issues with the deployment of staff.”
critical“The quality assurance and governance arrangements in place were not reliable or effective in identifying shortfalls in the service.”
medication management
2 findings
moderate“For one person, staff removed medicines and left on their table for person, this is recorded as 'medication to be prompted', then in their 'All about me' document, states...medication to be administered.”
moderate“Where people continuously refused their medication, records did not show that staff had taken any action in response to this such as referring this to a healthcare professional.”
care planning
2 findings
minor“One person who had a catheter in situ had a generic catheter care leaflet in their care plan...with no guidance as to what assistance was required.”
critical“Risks relating to people's health and wellbeing, for example where a person had a catheter or stoma fitted...had not been considered or recorded.”
staffing levels
2 findings
moderate“On the days their regular carer(s) were off, the timing of their visits became erratic particularly at the weekend. One relative told us, 'weekend people are often the office staff and they are just in and out.'”
critical“We are so short staffed, that's why everyone is getting late and missed calls.”
record keeping
2 findings
moderate“The auditing process had failed to identify people were not receiving their care calls at their scheduled time as stated in their care plan and where improvement was needed.”
moderate“the risk assessments for three people recorded these were last completed in October 2019, December 2019 and August 2020.”
infection control
2 findings
critical“Staff told us they had not always been made aware where people using the service had tested positive for COVID-19.”
moderate“Not all staff had received specific training relating to COVID-19 or 'donning and doffing'.”
staff training
1 finding
moderate“Not all staff had up to date mandatory training, with many courses seemingly completed over a one or two-day period.”
staff competency
1 finding
moderate“Not all staff had been trained to provide safe catheter and stoma care.”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
incident learning
1 finding
moderate“When things go wrong, lessons were not always learned to support improvement, and this was evident from our findings at this inspection.”
communication with families
1 finding
moderate“people told us they were not always contacted by Ashley Care if staff were running late or where there was a change of carer.”
safeguarding
1 finding
moderate“Where safeguarding concerns were raised, and an internal investigation undertaken, not all investigations completed by the registered manager were robust.”
person centred care
1 finding
moderate“People told us their care could be rushed and meant staff did not have the time to chat with them.”
other
1 finding
critical“the provider had failed to notify the Care Quality Commission without delay of incidents...seven safeguarding adult concern forms had been raised...but a statutory notification was not submitted.”