minor“We identified, the analysis was not fully reflective of the feedback received and gave limited useful information to support the service to develop.”
critical“the quality monitoring system did not effectively identify and address people's concerns regarding calls not happening at the agreed times and lasting the full duration.”
staffing levels
2 findings
minor“A small number of staff felt support, communication, and staffing at weekends could be improved upon.”
moderate“The provider did not effectively deploy staff to meet the needs of the people they supported.”
medication management
1 finding
critical“Where MAR charts were in place, they were not always up to date with prescribed medicines for each person and did not detail the correct level of support people needed.”
missed or late visits
1 finding
critical“Of these 27, 13 reported late calls, issues with staffing or not knowing which staff member would attend. Staff told us morning calls can run up to one o'clock in the afternoon”
care planning
1 finding
critical“Care plans did not always reflect people's current needs and there was a lack of clear guidance for staff on how to manage people's conditions safely.”
infection control
1 finding
critical“We were not assured staff were using personal protective equipment (PPE) effectively and safely in accordance with government guidance.”
record keeping
1 finding
moderate“Oversight of records relating to the care and treatment of people using the service was not sufficient. The provider's own checks had not identified records were not all up to date”
supervision appraisal
1 finding
moderate“Staff did not receive annual reviews, regular supervision, or regular spot checks.”
leadership
1 finding
moderate“We received mixed views from staff about the leadership of the service... 'The support for the staff isn't good.'”
person centred care
1 finding
moderate“People did not always receive person centred care... 'I never know when they are coming,' and another said, 'They don't let me know if they are running late, they just turn up.'”
communication with families
1 finding
moderate“There was a lack of systems and processes in place to ensure people were reliably informed about changes to their care workers.”
other
1 finding
critical“Staff were not always recruited safely... not all had two references or full employment histories.”