critical“The provider's systems and processes to assess, monitor and mitigate risks across the service were not always effective. This was a breach of Regulation 17 (2) (a) (b) [Good governance]”
care planning
1 finding
moderate“Risk assessments and care plans were detailed. However, they were not always updated, after a review or when circumstances changed.”
missed or late visits
1 finding
critical“New referrals had not always been entered promptly onto the service's electronic tracking system. This meant staff monitoring the tracker had not picked up a number of missed visits.”
safeguarding
1 finding
critical“We found examples however where the service had dealt with concerns but had not raised appropriate referrals.”
staff competency
1 finding
moderate“A social care professional said, 'I don't use Violet Care for people with complex needs as I can't guarantee their safety.'”
incident learning
1 finding
moderate“There were some gaps in investigations, for example, why staff had not called 999 in an emergency. This meant the registered manager had not picked up the above concerns.”
record keeping
1 finding
moderate“40% of call times had been manually inputted by staff who had recorded they had completed visits exactly as planned... none of these hundreds of visits had been shorter than planned.”
communication with families
1 finding
minor“A relative said, 'When I complained about poor care, I kept getting different managers and staff phoning and apologising.'”
person centred care
1 finding
minor“Staff just handed my family member an orange but didn't realise they had forgotten how to peel it. Person will stop eating if no one is there to encourage them.”
leadership
1 finding
moderate“The provider told us saw their role as being one of 'developing people to be leaders in adult social care,' rather than being involved in the day to day running of the service.”