critical“one person's care plan showed their scheduled visit was from 8.00pm for 30 minutes, but they were visited at 9.46pm that was one hour 46 minutes late”
staffing levels
1 finding
critical“Staff were not effectively deployed at all times to support people... some staff calls were not always scheduled as agreed with people.”
care planning
1 finding
critical“one person's care plan showed their scheduled visit was from 9.00am for one hour, however they were visited for nine minutes”
medication management
1 finding
moderate“staff recorded in the care log that they administered medicines but the MAR chart was blank for a night's medicine on one day”
record keeping
1 finding
moderate“There was no communication record to show that the office staff had informed people when staff were running late to their scheduled home visits.”
governance
1 finding
critical“The provider's quality assurance systems were not robust. The provider was not effectively monitoring people's calls to ensure that these were taking place as planned.”
leadership
1 finding
moderate“The registered manager did not have an effective oversight of the service. The quality assurance system and processes had failed to identify and correct issues”
incident learning
1 finding
moderate“two medicines related incidents were picked up and notified to CQC but not recorded on the June 2021 checks.”
staff training
1 finding
minor“a member of staff was not aware about the procedure for reporting any wrongdoing internally to their line manager or to relevant external organizations in line with the whistle-blowing”
consent capacity
1 finding
minor“Staff had received MCA training however a member of staff we spoke with did not understood people's rights under this legislation.”