critical“There are always tablets remaining that [family member] hasn't had. I've found tablets on the floor. A whole packet of tablets as well.”
missed or late visits
1 finding
critical“78.1% of calls (5555 of care calls in total) had no travel time built in... 14% of people had less than half of the planned duration delivered.”
staffing levels
1 finding
critical“The timings are all over the place. They are usually late, it's happening a lot recently, I think they are short staffed.”
governance
1 finding
critical“The provider had failed to establish effective quality assurance and governance systems that identified areas of risk and improvement needed within the service.”
leadership
1 finding
critical“The registered manager did not have enough oversight of the service. They did not maintain a presence at the service or undertake any management audits.”
care planning
1 finding
moderate“A risk assessment for one person stated there was no issue with their skin integrity. This was despite them using three topical creams for their skin.”
record keeping
1 finding
moderate“People's care records did not always include clear guidelines for staff in how to manage risks to their care.”
staff training
1 finding
moderate“The provider had not heard about this training and staff working for Forest Homecare Suffolk had not undertaken it [Oliver McGowan Mandatory Training].”
consent capacity
1 finding
moderate“Staff training in record keeping needed to be improved in relation of the use of the Mental Capacity Act 2005 (MCA).”
incident learning
1 finding
moderate“The provider was not able to demonstrate how they monitored or managed missed, late and shortened care calls. There was no system in place to enable this.”
person centred care
1 finding
moderate“People were not empowered to influence the care and support they received.”
communication with families
1 finding
minor“We've not had any surveys. They don't listen. Communication isn't as good as it should be.”