critical“Management had not sufficiently improved their governance processes to ensure they provided a consistently good quality service as we received comments from people around poor time keeping and late and missed calls.”
critical“The lack of good governance of the service was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
critical“The lack of monitoring of the service to ensure good outcomes for people, robust auditing, contemporaneous record-keeping and general governance was a breach of Regulation 17.”
missed or late visits
3 findings
moderate“"I never know when the carers are to visit or how long they should be staying" and, "I'm not sure why I only get 15-minute visits when I am paying for 30 minutes."”
moderate
“Timing of calls is an issue. Sometimes they can be here before nine and some days it's way after nine”
critical“They don't stay the allotted time of 30 minutes – they are there approximately ten minutes. A relative told us, "We were lucky if we got four or five minutes."”
record keeping
3 findings
moderate“There was a lack of understanding of the requirements of registration. We discovered the agency was providing care to people living in Sussex, although we had not been told this prior to our inspection.”
moderate“There continued to be a lack of effective systems and overall governance of the service…a disparity between care plans, with some containing good information and others not.”
moderate“On one person's log sheets staff had repeatedly not filled in leaving time. In another's, staff had not stayed the length of time in line with the person's support plan.”
infection control
2 findings
minor“"No masks or aprons, but most wear gloves" and, "Not all carers wear aprons or gloves"”
critical“The guy who came today didn't have any gloves on him and I didn't have any in the home. Some are wearing masks, and some are not wearing them.”
medication management
2 findings
moderate“staff were not recording the dosage correctly on one person's medicine record as they had been writing ½ tablet in the book, rather than 1½ tablets”
critical“We found handwritten medicine details for people which lacked prescription information. The MARs we looked at only had people's first names, no GP information, no record of allergies.”
care planning
2 findings
moderate“there was a lack of detail in relation to one person's diabetes and a second person who was at risk of neglect. However, daily records showed staff knew people well”
critical“We noted a document stating 37 people did not have a support plan. We found commencement dates of June 2019, November 2019 June 2020 and December 2020 amongst those without a support plan.”
person centred care
2 findings
moderate“one person was recorded in their care plan as being at risk of social isolation…care calls were regularly recorded as 15 or 20 minutes instead of half an hour”
moderate“There was a lack of person-centred information in the support plans we reviewed. I just feel like a dot on the map.”
incident learning
2 findings
minor“one person was found unresponsive when the carer arrived. There was little detail on the incident form as to what action the carer took”
moderate“We did not see any evidence of what had been done about the delay in producing support plans, missed calls for people or staff not staying the full length of time at care calls.”
staff training
1 finding
moderate“20 of the 27 staff had not received learning disability training despite the agency being registered to provide care to people in this service user band.”
communication with families
1 finding
moderate“The service did not have good communication systems in place. "Today we were called to tell us the carer was running late. This is the first time that anyone has done that."”
safeguarding
1 finding
critical“The lack of systems and processes to effectively prevent abuse of service users was a breach of Regulation 13 of the Health and Social Care Act 2008.”
complaints handling
1 finding
critical“The agency did not hold a complaints log giving information on complaints received, action taken and outcome. People told us they were unsure on who they could report complaints or concerns to.”
leadership
1 finding
moderate“I don't think [registered manager] understands her responsibility and how to take action. She seems to just fob us off with a response that makes no sense.”
staff competency
1 finding
moderate“Despite staff receiving the opportunity to take training in areas such as infection control and safeguarding, we identified shortfalls in their practices.”