critical“People were exposed to the risk of harm because the systems in place to safeguard people from harm and abuse were not followed properly by staff.”
governance
1 finding
critical“Systems were not robust enough to demonstrate quality and safety was effectively managed.”
staffing levels
1 finding
critical“The provider failed to ensure sufficient staff were employed to meet people's needs.”
missed or late visits
1 finding
moderate
“They are not always on time. They are sometimes an hour late...the agency stated they were short staffed and couldn't get anyone.”
communication with families
1 finding
moderate“people were not always informed of who was scheduled to attend their care calls and were not informed when carers were running late.”
complaints handling
1 finding
moderate“others told us they had raised complaints with the service but not received a response.”
incident learning
1 finding
moderate“Although accident and incidents were recorded, these were not easily accessible during the inspection. It was clear the system in place to manage accident and incidents were not effective.”
leadership
1 finding
critical“The registered manager who was also the provider, did not provide effective oversight and governance of the service's safety and quality to ensure all regulatory requirements were met.”
record keeping
1 finding
moderate“We found up to date records were not kept regarding improvements made to the service.”
person centred care
1 finding
moderate“Due to poorly coordinated visits and shortage of staff, people did not always receive support at their preferred times, their routine was disrupted because staff were late”
staff competency
1 finding
moderate“We feel safe with the regular carers, but not the stand ins, they don't seem to know what they're doing and I have to tell them what to do”
other
1 finding
minor“The registered manager and staff we spoke with were not fully aware of the legal requirement to follow the Accessible Information Standard.”