moderate“Only 73 per cent of calls were on time and 9 per cent of calls were more 45 minutes late. 18 per cent of calls were short and staff did not stay for the duration of the call.”
moderate“We checked the rotas and found enough time was not always planned between calls... they don't take into account travelling time when booking visits.”
moderate“There were enough staff to meet people's needs but they were not always deployed effectively.”
governance
3 findings
critical“The provider had failed to carry out regular audits to identify issues. There were no audits carried out for care plans, the ECM system or for staff files.”
critical
“The provider's systems to oversee quality and the safety of the service were not always effectively operated. Medicines audits had not identified the concerns we found”
moderate“The call monitoring system, introduced following the last inspection, did not provide accurate oversight of people's call times and durations.”
record keeping
3 findings
critical“Application forms were not always completed fully, and the provider had failed to obtain each applicant's complete and accurate employment and education histories.”
critical“Medicines administration records (MAR) were not always legible and did not include the specific dose to be administered.”
minor“Where paper medicines records had been used due to problems with the electronic system these were not always audited to ensure any issues were addressed.”
care planning
2 findings
critical“Risk assessments and risk management plans were not always in place. Risks to people such as those associated with falls, and medicines had either not been assessed adequately.”
moderate“Where people had a diagnosis of epilepsy there were no risk assessments to guide staff on possible signs and triggers to reduce risk”
medication management
2 findings
critical“People who were prescribed PRN medicines did not have a PRN protocol in place with clear guidance for staff on how or when to administer medicines to them.”
critical“Medicines were not always safely managed. Medicines risk assessments did not always fully detail or assess the possible risks to people.”
staff competency
2 findings
moderate“Regular medicine competency assessments were not carried out to ensure staff had the skills to administer medicines safely.”
moderate“most staff had not completed medicines competency record to assure the provider of their competence to administer medicines.”
incident learning
2 findings
moderate“Where medicine audits did identify shortfalls, records showed that follow up actions were not documented.”
moderate“Staff were reporting accidents and incidents to the office by phone but not completing a full written record of their actions when they involved a person using the service.”
leadership
2 findings
critical“The registered manager did not have an adequate understanding of their role, regulatory requirements and lacked oversight of the service.”
moderate“six people or their relatives thought the service was not managed well because of the issues with call scheduling and care workers not always completing tasks.”
missed or late visits
2 findings
moderate“two people and two relatives told us that staff did not always stay the full length of their calls... 'They have been 90 minutes late four or five times in the last few months.'”
moderate“People told us they did not always receive their calls at the right times and they could be rushed and not always for the planned duration.”
communication with families
1 finding
moderate“Some people and relatives also said that they did not know who the registered manager was. A relative said, 'I don't know the manager. I tried to speak to the office... They don't answer the phone.'”
other
1 finding
critical“Recruitment records did not always show the provider had completed the required recruitment checks on staff. The provider did not record full employment histories”
supervision appraisal
1 finding
minor“Staff said they received regular supervision to support them in their roles. However, this was not always evidenced from records.”
person centred care
1 finding
moderate“some calls were cut short, some people experienced a lack of consistency of care workers and care workers rushing when delivering support.”