critical“The times they come vary greatly, today was 9am but sometimes it's 10am or even later”
critical“Monthly alert data from January to April 2021 showed over 40 percent of visits had been at least 30 minutes late each month. The service's target was 10 percent.”
moderate“"My only problem is the weekends, they are supposed to come between 8 and 9am but sometimes it is 11am, they don't ring to say they will be late"”
moderate“"It's a problem when my morning call is late, because I need help getting to the toilet and that can't wait."”
record keeping
3 findings
moderate
“The directions for how to administer a person's medicine had not been updated following a GP review.”
critical“Medicine administration records (MARs) were not accurate, despite the checking system in place. Care plans did not accurately detail the support people required with their medicines.”
minor“medication monitoring sheets did not record individually what medication had been administered from the 'Veralink' by staff”
governance
2 findings
critical“There was no clear audit schedule in place, which detailed what audits and monitoring was completed and how often.”
critical“Governance systems were not robust enough to ensure issues with service delivery were either identified or addressed timely. This was a breach of regulation 17.”
medication management
2 findings
moderate“2 people's medicine administration records (MAR) contained incorrect information regarding their allergy status.”
critical“Controlled drugs were not managed safely. Records to monitor stock levels were not in place and staff had not consistently documented if these medicines had been given or at what time.”
communication with families
2 findings
moderate“No surveys or questionnaires had been circulated since the last inspection in May 2021.”
moderate“It's difficult to get through to the office, then there's no follow up to calls we've made to update us on what is happening.”
care planning
2 findings
moderate“We identified some inaccuracies and omissions within the care plans we viewed on inspection. These issues had not been picked up by the registered manager.”
moderate“Where family shared medicines responsibility, care plans were not clear how this would be managed.”
person centred care
1 finding
critical“People who had specifically requested female care staff, due to requiring personal care, had, on occasions, been supported by male care staff.”
safeguarding
1 finding
moderate“Training records showed significant gaps in completion rates for safeguarding training.”
incident learning
1 finding
moderate“Prior to this system being implemented, it was not clear what analysis had been completed of incidents and accidents.”
supervision appraisal
1 finding
moderate“An action plan linked to supervision completion, care plan review completion, staff observations and competency checks, all of which were not up to date.”
complaints handling
1 finding
minor“I have had to complain about a few things...They said they would investigate, but no-one has come back to me.”
consent capacity
1 finding
minor“a number of staff were unable to explain the principals and either told us they had received no training or could not remember whether they had received training”