minor“some people told us this was not always the case. We received feedback that some individual staff did not engage with people nor always listen to what they said.”
minor“a person told us that at weekends they did not always get their preferred gender of care workers and they had raised this with the office, but this was not addressed”
minor“One person's relative said that their family member's usual care workers knew about their needs, but when they had newer care workers, 'They do not appear to be aware of what they are doing.'”
moderate“The care records did not include people's preferences regarding the gender of the care workers who visited them in their own homes.”
missed or late visits
4 findings
moderate
“one person said about their care workers being late, "What can you do? I'm used to them. I think it's because they are short staffed."”
moderate“morning visit ranged from 9am to 11.40am and the afternoon visits ranged from 4.05pm to 5.15pm”
moderate“One person's relative said this was a problem, because their family member was waiting for support with their personal care and when their care workers did not arrive on time, this affected them.”
critical“One day they did not turn up until 1.40pm should be after 7am and before 8.45am...this concerned them because the person had to have medicines in the morning.”
medication management
3 findings
minor“a relative told us how tablets had been found in their family member's bedding, which had been reported to the office and they were assured this would be looked into.”
moderate“There were times when the visits between the two were not always coordinated which resulted in them not being able to take their pain medicines, because their visits were too close together.”
critical“Training records did not demonstrate that all staff had received up to date training in the safe administration of medicines or that those that had received training had had their competency regularly checked.”
communication with families
3 findings
minor“whilst some said they were told when their visit was running late, some said they were not.”
moderate“"Sometimes I get in a muddle and I need help quickly. I ring the office staff but they don't help me and don't pass my messages to the carers."”
moderate“Communication could be better as it is very poor when there are no phone calls to say sorry they are late.”
record keeping
3 findings
critical“where care workers had a previous criminal conviction there were no risk assessments or records in place to show how the service had considered this”
moderate“Of the 11 care records we reviewed only two had the specific times that visits were to be completed.”
moderate“Safeguarding records were currently kept on the service's e mail systems and were not analysed and did not give a clear audit trail of actions taken.”
governance
2 findings
moderate“for the late visits there was no time on the planned visit time and how late they were. Without this information, the service cannot effectively assess late visits.”
moderate“The provider's quality assurance systems were not robust enough to identify shortfalls in the service and to take actions to address them.”
staffing levels
2 findings
moderate“care workers did not always stay for the agreed length of time. They said that sometimes it could total up to two hours each week that they had cut short visits.”
moderate“I can be half way through one round then get a phone call to say there has been a change to the rota so not enough staff.”
complaints handling
1 finding
moderate“The managing director had identified that there had been some complaints which had not previously been addressed appropriately.”
infection control
1 finding
minor“We were told in a concern received about the service that the care workers had not used gloves or aprons when they were supporting a person with their personal care needs.”
safeguarding
1 finding
critical“The training records of care workers were not up to date therefore we could not be assured that all staff had received up to date safeguarding training.”
staff training
1 finding
moderate“Of the 57 care workers listed 25 had training in diabetes and 42 had received training in dementia.”
supervision appraisal
1 finding
moderate“Of seven care worker personnel files reviewed only one had received a one to one supervision meeting in 2016.”
care planning
1 finding
moderate“Not all had been assessed by the service and the care plans in place remained from their previous care provider.”
incident learning
1 finding
moderate“There was a log maintained about where missed calls had happened. However, not all of these included actions taken to reduce the risks of these happening in the future.”
cultural competency
1 finding
minor“We had received comments from people about the difficulties they faced when they were supported by people who did not use English as their first language.”