critical“People did not always receive their medicines as prescribed. Some people were prescribed medicine in a patch format to treat pain. We found on several occasions this medicine had not been administered as prescribed.”
missed or late visits
1 finding
moderate“People did not always receive their care calls at the agreed time due to insufficient staff deployed by the service.”
staffing levels
1 finding
moderate“Staff felt more staff were needed to ensure all calls were made on time and for staff rotas to be managed well to make sure staff absence such as leave or sickness was adequately covered.”
safeguarding
1 finding
critical“the safeguarding log was not kept up to date as per policy. There was a risk of concerns not being reviewed, resulting in the risk of ongoing harm to people.”
governance
1 finding
critical“The provider lacked oversight to identify and address areas for improvement in a timely way... The compliance audit procedure in place did not identify or address issues until a month after the incident.”
complaints handling
1 finding
moderate“complaint outcomes were not always communicated effectively or in a timely manner. People told us they were not happy with how their concerns and complaints were processed.”
communication with families
1 finding
minor“Not everyone received their calls on time or were informed by the office staff if their call was going to be late.”
leadership
1 finding
moderate“Temporary management support arrangements put into place by the provider were not always effective.”