moderate“The registered manager did not have oversight of accidents and incidents, so patterns and trends could not be identified.”
moderate“From speaking with staff, we identified that there had been some minor incidents which should have been recorded.”
critical“the registered provider had failed to notify the Commission of an event that prevented the service provider's ability to continue with a regulated activity safely.”
critical“The registered provider failed to inform the Commission as required of their inability to provide care and support to people who used the service until 10 October 2016.”
critical“The registered provider failed to inform the Commission as required [of their inability to deliver care calls to 17 people on 8 and 9 October 2016].”
medication management
4 findings
critical“One person's medication administration records (MAR's) were missing, therefore there was no evidence to show staff had recorded or administered this person's medicines, as prescribed.”
critical“Staff were not provided with protocols for administering 'as and when needed' (PRN) medication.”
critical“There was no guidance available to staff to administer one person's medication covertly.”
critical“Staff arrived 101 minutes late to a scheduled call which meant the person did not have their medicines at the required three hourly intervals.”
care planning
4 findings
moderate“Risks were not always recorded clearly in people's care plans. This meant staff did not always have access to current information about people's needs and ways to minimise risks.”
moderate“people did not receive person centred care and their care plans lacked information to enable staff to deliver care in line with their preferences.”
critical“Care plans had not been created for two people who used the service and other people's care plans failed to reflect people's current support needs.”
critical“care plans did not reflect people's current level of needs and lacked pertinent information they needed to deliver the care people required safely”
governance
4 findings
critical“There was no formal system in place for carrying out or recording these checks had been made.”
moderate“we could not rate the service higher than requires improvement for 'well-led' because to do so requires consistent and sustained improvement over time.”
critical“The registered provider's quality monitoring systems were inadequate. There was no evidence to show that auditing of care plans, risk assessments, staff training and supervision... was carried out.”
critical“They did not operate effective governance systems and relied upon ad-hoc checks to monitor the quality of service delivery.”
person centred care
3 findings
moderate“Care plans contained minimal person-centred information about their routines, life history, hobbies and interests.”
moderate“The care plans we saw did not contain personal information about people such as their hobbies and interests, their family lives or the previous occupations.”
critical“One care plan contained no information about the person's needs so staff delivering care would not have known what the person required assistance with”
record keeping
3 findings
moderate“People's care files did not always contain records of reviews held which reflected what had been discussed or agreed at the meeting.”
critical“Complete and contemporaneous records were not held regarding each person who used the service. Two people who used the service did not have care plans.”
moderate“due to the poor record keeping and lack of information in the service we could not conclusively determine when or how the complaints were received”
staffing levels
3 findings
critical“the registered provider could not deploy suitable numbers of staff to meet the needs of the people who used the service, which led to people experiencing missed calls.”
critical“The registered provider could not deliver commissioned care to 17 people totalling 102 care calls between 8 and 9 October 2016.”
critical“inability to deliver care and support to 17 people during the weekend of 8 and 9 October 2016, which equated to over 100 care calls”
missed or late visits
3 findings
critical“We used to be rushing from one call to the next, leaving early to try and get to the next one on time but all that's has stopped now.”
critical“Staff arrived up to 179 minutes late and up to 177 minutes early to care calls. 52 calls were completed in less than 10 minutes and 19 were completed in less than five minutes.”
critical“records also showed staff arrived up to 179 minutes late and up to 177 minutes early to care calls”
staff training
3 findings
moderate“staff had not completed relevant training and were not supported in their roles.”
moderate“One member of staff completed assessments of people's needs before producing care plans and risk assessments... they had not completed training in this area.”
critical“None of the staff files we looked at contained an annual appraisal, even though staff had worked for the registered provider since 2013”
complaints handling
3 findings
moderate“complaints were not recorded and investigated as required.”
moderate“Five complaints contained no information except for the complaint, no acknowledgement, no investigation and no response.”
moderate“Internal investigations had not taken place and subsequently the service had failed to learn from any of the concerns raised”
safeguarding
3 findings
critical“the registered provider had failed to ensure people were not exposed to risk of abuse by way of neglect. People...had their care calls delivered in significantly reduced timescales.”
critical“People were exposed to the risk of abuse by way of neglect because the registered provider could not deploy sufficient numbers of staff.”
critical“81 calls were delivered in less than half of the time staff would need to deliver the care the person required. 52 calls were completed in less than 10 minutes”
staff competency
2 findings
critical“Newly recruited staff with previous experience working in the care sector were allowed to support people without having their skills and abilities checked.”
critical“one of the DBS checks showed the person had a number of recent convictions. There was no risk assessment or record of any conversation with the staff member”
supervision appraisal
2 findings
moderate“None of the seven staff files we looked at contained an annual appraisal, even though staff had worked for the registered provider since 2013.”
critical“There were no supervision records available in any of the staff files we looked at.”
leadership
1 finding
critical“The registered manager told us, 'I knew we had loads of problems, we knew something serious was going to happen to someone.'”