critical“The provider failed to assess, monitor and improve the quality and safety of the service effectively. Regulation 17 (1) (2)”
critical“Quality assurance systems were not effective as they had not identified all the issues we found with care plans, risk assessments, medicines support and the anomalies with care visit times.”
missed or late visits
2 findings
moderate“ECM showed planned visit times and actual visit times varied up to 2 hours difference for some people's visits.”
critical“the provider submitted a late visits report that showed there were 8,379 late visits between March and August 2022”
care planning
2 findings
moderate“We continued to find conflicting information in care and medicine records which had not been resolved through the providers quality assurance processes.”
moderate“We found conflicting information in people's care plans about the level of support they required.”
medication management
2 findings
moderate“One person was taking an anti-coagulant medicine but the additional risk of bleeding associated with this medicine were not considered.”
critical“People's medicines were not always managed safely. Care plans contained conflicting information about the level of support people required to take their medicines.”
record keeping
2 findings
moderate“One person's MAR indicated the medicines had been left for the person to take later. However, care notes for these days stated that medicines had been administered by staff.”
moderate“The ECM system was recording different times to the times recorded on care notes and MARs so we could not be certain which system was correct.”
person centred care
2 findings
minor“The provider had not made necessary improvements based on feedback from people. One person told us, 'I have spoken to the office several times about the timing for my medication.'”
moderate“People did not always get person-centred, high quality care.”
staffing levels
1 finding
critical“The provider had failed to ensure sufficient staff were deployed to meet people's needs.”
staff competency
1 finding
moderate“Staff received training in the administration of medicines, however, their competency had not been assessed in line with best practice guidance.”
leadership
1 finding
moderate“The culture of the organisation is unapproachable, rude and dismissive.”
incident learning
1 finding
moderate“The provider's investigation into the missed visits did not show what the root cause of this incident was so we could not be assured that the provider was able to learn lessons”
communication with families
1 finding
minor“I've never been contacted by the manager to check how things are going”
complaints handling
1 finding
moderate“I have complained about not having a regular carer but the management haven't done anything about it.”