critical“People were at risk of harm as there was impact to people's safety and well-being where calls were very late.”
critical“There was impact to people's safety and well-being where calls were missed or were very late.”
staffing levels
2 findings
critical“Rotas were not managed effectively so people received care when they needed it. This placed people at risk of harm.”
critical“Rotas were not managed effectively so people received care when they needed it. This placed people at risk of harm.”
governance
2 findings
critical“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.”
critical“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.”
person centred care
2 findings
moderate“The culture of the organisation did not promote a person-centred approach to delivering care or an openness which empowered staff and people.”
moderate“The culture of the organisation did not promote a person-centred approach to delivering care or an openness which empowered staff and people.”
communication with families
2 findings
moderate“People were not routinely informed when their call was going to be late.”
moderate“79% of people and relatives and 65% staff commented that communication was ineffective.”
medication management
2 findings
moderate“improvements were still required to medicines management to ensure all people received their calls at the scheduled times.”
critical“Medicine Administration Records (MARs) showed that there were occasions medicines were not given to people at the prescribed and scheduled times.”
incident learning
2 findings
moderate“the provider had failed to ensure learning and take decisive action to improve the care people received.”
critical“Safeguarding incidents were investigated but they did not show evidence of effective lessons learned as there was no sustained improvement and there were recurring themes.”
complaints handling
2 findings
moderate“Complaining and getting a response is a lottery but the issues are not resolved.”
moderate“I have complained by phoning the office who apologise but nothing changes. I have completed a questionnaire, but no response or changes made.”
leadership
2 findings
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
critical“There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
other
2 findings
critical“People were not always supported to have enough to eat and drink at regular intervals.”
critical“Rotas were not managed effectively so people received food and drink at regular intervals. This placed people at risk of dehydration and malnutrition.”
safeguarding
1 finding
critical“Systems were either not in place or embedded to ensure appropriate and timely action was taken to safeguard people at risk of abuse.”
staff training
1 finding
moderate“Effective systems were not in place to ensure staff were trained and competent to carry out their role to ensure people's care and safety.”
staff competency
1 finding
moderate“Several staff members reported they did not feel competent to provide some care.”
record keeping
1 finding
moderate“Care records were electronic, they were not backed up so when there were technology failures, information was not available to ensure people's needs were met.”