moderate“The management team had not used audits to identify gaps in care plans and risk assessments. This meant that some care plans lacked up to date information.”
moderate“The provider's systems and processes to monitor the service were not always effectively operated or embedded as they had failed to identify the issues we found in relation to recruitment files and risk assessments.”
care planning
2 findings
moderate“Risk assessments were not always completed or did not record full information about risk. For example, we found one person did not have a falls risk assessment.”
moderate“Risks associated with people's health needs were not always clearly documented. For example, clear guidance was not in place for staff to follow in the event of a person having an epileptic seizure to keep them safe.”
missed or late visits
2 findings
moderate“One relative said, 'I wouldn't recommend them due to not turning up.'”
minor“One person said, "I never know whose coming or what time, I would prefer to know." ... Call logs viewed during the inspection confirmed the timing of calls did vary for some people.”
supervision appraisal
1 finding
moderate“The management team did not always record when spot checks of staff practice had taken place so could not be fully assured all staff were competent in their roles.”
medication management
1 finding
minor“Medicines audits required further improvement, to ensure they were completed in a timely manner to ensure mistakes are followed up straight away.”
communication with families
1 finding
minor“People and relatives views about communication with managers was mixed. This related to call times and not always being informed if calls would be late or missed.”
incident learning
1 finding
minor“Feedback provided to the service was not used to support quality improvement. People had completed surveys, but these had not been analysed to understand themes.”
staff competency
1 finding
critical“Staff were not always recruited safely in line with the providers policies. During the inspection, we identified gaps in the employment references for five staff members.”
record keeping
1 finding
moderate“Two people's care plans had not been reviewed, in line with the providers policy. We identified one review was overdue by five months, another was overdue by one month.”