minor“I have had a very wide window of time when the carers are meant to arrive in the evening... between 5:30 and 9:30 pm. As a result, I never knew exactly when the carer was going to arrive”
moderate“They arrive on time most of the time, but at times they can be late. Recently they missed a call completely.”
record keeping
2 findings
minor“a female carer had turned up and only stayed for 20 minutes, but signed the black book saying that she had been here longer”
moderate“failing to have a complete and contemporaneous record for people was a breach of Regulation 17 (good governance).”
medication management
2 findings
critical“PRN protocols contained contradictory information... one person had been overmedicated for a long period of time which posed a risk of liver damage.”
critical“Sometimes there is no information regarding medication on site so new staff are struggling. Sometimes we find missed medicines, new carers do not know what to do.”
infection control
1 finding
critical“The provider had failed to mitigate risk in relation to infection, prevent and control. This placed people at risk of infection.”
governance
1 finding
critical“Quality systems were not effective or robust in identifying and driving improvement across the service. The shortfalls we found during our inspection had not been identified by the provider.”
care planning
1 finding
moderate“Some care plans did not contain enough information to instruct staff and did not always follow best practice guidance.”
staff training
1 finding
moderate“There are gaps in training. Medication training was online and was only provided by the management after things were raised with the local council.”
communication with families
1 finding
moderate“the majority of people's relatives told us they did not feel engaged and that communication between them and the provider's office needs improving.”
leadership
1 finding
moderate“Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
person centred care
1 finding
minor“People's preferences for a male or female care worker were not always explored before commencing provision of care.”