critical“67% of visits had no travel time between each visit... 11% of visits were less than half the planned duration and 41% of visits were between 50% and 90% of the planned length”
staff competency
1 finding
moderate“staff who undertook visits did not always know how to support them. People said they were spending the time they should be receiving care explaining to staff how to provide care”
governance
1 finding
critical“Governance systems in place were not robust enough to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.”
record keeping
1 finding
critical“Care plans were not always kept up to date and current... one part stated there were no medical conditions recorded, and in another part listed the person's conditions.”
supervision appraisal
1 finding
moderate“not all of the staff files included 1 to 1 staff supervision and appraisals and where these were in place, they had not followed up on the shortfalls identified in spot checks”
person centred care
1 finding
moderate“The language and ways of describing the support provided used in some daily records was not always person centred or respectful.”
communication with families
1 finding
moderate“One person said they received, 'Zero,' contact from the office, 'The only time I speak to anyone from the office is when I call them.'”
care planning
1 finding
moderate“there were 2 care plans being used for people... a risk that staff may not always read the 2 sets of care records and potentially miss information of how to keep people safe.”
medication management
1 finding
moderate“some records were contradictory regarding who supported people with their medicines... prompts on the electronic system for what creams were to be administered, this was not in the main body of the care plans.”
incident learning
1 finding
minor“the oversight in the service needed improvement to ensure all actions taken were recorded.”
leadership
1 finding
moderate“There was no registered manager in post. The last registered manager deregistered in March 2023.”