critical“The provider had failed to ensure there were sufficient levels of staff, and that staff are effectively deployed. This was a breach of Regulation 18.”
missed or late visits
1 finding
critical“People often did not receive their calls at the agreed times and calls could take place hours later than planned.”
medication management
1 finding
critical“The provider had failed to ensure the proper and safe management of medicines. This was a breach of Regulation 12.”
safeguarding
1 finding
critical“The provider had failed to establish effective systems to prevent abuse, and to effectively respond to any allegation or evidence of abuse. Breach of Regulation 13.”
governance
1 finding
critical“The provider had failed to implement effective systems to assess, monitor and improve the quality and safety of the service. Breach of Regulation 17.”
complaints handling
1 finding
critical“The provider did not have effective systems to make sure all complaints were investigated without delay...This was a breach of Regulation 16.”
care planning
1 finding
moderate“People's care records lacked enough guidance and information about their individual support needs, for example, diabetes and dementia care.”
staff training
1 finding
moderate“The current available training matrix showed gaps in core areas such as the Mental Capacity Act, moving and handling and medicines support.”
supervision appraisal
1 finding
moderate“Managers told us that planned regular supervisions and spot checks had lapsed in recent months.”
record keeping
1 finding
moderate“The provider failed to ensure records were accurately maintained. In October 2022, a person was prescribed thickener for their drinks...none of the relevant records reflected this change.”
incident learning
1 finding
moderate“Information of concern had not been effectively learned from or shared with relevant partners to continuously improve the safety of the service.”
consent capacity
1 finding
minor“Staff did not demonstrate good understanding of the requirements of the MCA, though most staff could describe how they promoted people's choices.”
end of life care
1 finding
moderate“Managers told us two people were at end of life. Their records had not been updated to provide detail about any changes to the level of care required.”
person centred care
1 finding
moderate“Managers were trying to address concerns whereby the service had adapted to staff need and preference, rather than that of people using the service.”