critical“They come sometimes at the wrong time, they are supposed to come between 12-1.30pm but sometimes they come at 3.30pm or after 4pm.”
critical“The provider had not deployed sufficient numbers of suitably qualified, competent, skilled and experienced persons.”
missed or late visits
2 findings
critical“care visits did not always take place on time and were not always completed by 2 staff when this was needed.”
critical“high levels of lateness with little or no travel time planned, and staff being logged into multiple places at once.”
governance
2 findings
moderate“a substantial number of calls still had no travel time planned, and staff were able to be logged into multiple places at the same time.”
critical“The provider's quality assurance systems did not identify the concerns we found and therefore were insufficient and ineffective.”
care planning
1 finding
critical“People's needs were not always assessed before they began using the service. We saw multiple instances where they relied solely on the information provided by the referral agent.”
consent capacity
1 finding
critical“There were no documentary records of people consenting to their care...the registered manager told us they used to seek written consent but had stopped since changing to a digital system.”
record keeping
1 finding
critical“numerous instances where records we would expect to see were either not in place, were missing entirely and or lacked information.”
medication management
1 finding
critical“The service was not keeping a record of these MAR charts in the office and therefore not auditing or checking whether the medicine had been administered.”
staff training
1 finding
moderate“nine staff not receiving infection control training, eleven staff not having health and safety training, seven not having medicines administration and nine not having safeguarding training.”
supervision appraisal
1 finding
moderate“the provider was unable to demonstrate staff were receiving regular supervision and a supervision matrix indicated as much.”
incident learning
1 finding
moderate“The service had an accident book, but it was blank and was not being used.”
safeguarding
1 finding
critical“we found numerous instances where there appeared to be missed calls...This resulted in our raising a safeguarding alert with the local authority.”
infection control
1 finding
moderate“the provider was not following government guidance with regards to staff testing...There was no system in place to monitor whether staff testing was occurring.”
person centred care
1 finding
moderate“The service was not promoting a positive person-centred culture...people were not receiving calls in a person-centred way.”