moderate“Some of the daily logs completed by staff were not always complete and accurate records of people's care.”
moderate“some recording by care workers was illegible, care workers did not always follow guidance on the care and support people needed.”
minor“we did find the provider had not reviewed or updated the risk assessment for one person and the care plan for a second person, in the records we checked”
moderate“Financial transaction records for one person who had received weekly shopping support for two years had not been collected so they could be audited.”
minor“On one of the 19 files we reviewed we noted that the provider had obtained and verified three character references from friends of the applicant. However, in the application form, the person said they had worked for three other care agencies”
minor“One file did not include a DBS check and the provider had noted that the care worker should only work alongside another carer until they received it.”
care planning
5 findings
critical“Some people's care plans appeared to be written in standardised terms with little personalised information about the person on how they preferred to be supported.”
critical“the provider told us they had reviewed and updated 100% of client files, information provided during the inspection showed the provider had reviewed only 20 of the 95 service user files.”
moderate“the provider had not reviewed one person's risk assessments for more than 12 months”
moderate“The provider did not always have up to date information about people's care needs and risk management plans.”
critical“Four people's plans were dated June 2017...these meetings did not inform a recorded re-assessment of people's needs or an update of their plans of care.”
person centred care
4 findings
critical“Some care plans had not been reviewed or updated since our last inspection visit in June 2019. For example, one person's plan was dated 2017.”
moderate“some daily care notes included inappropriate language that objectified or infantilised people using the service...referring to one person as 'deaf and dumb' and references to 'changing nappies.'”
minor“The carers are very task orientated, they come in and have to concentrate on getting the job done. It would be nice to have more time for a chat.”
critical“Plans gave basic information about the tasks care staff needed to complete, without always including information about people's preferences or the way they wanted to be cared for.”
governance
3 findings
critical“The provider's assurance systems had not identified and addressed in a timely manner that some people's care and risk management plans needed to be updated.”
critical“audits completed by the provider did not identify service failures. For example, there was no evidence of risk assessment reviews, some recording by care workers was illegible.”
critical“This system of checks had not consistently operated effectively as it had not identified the issues we found during the inspection.”
missed or late visits
3 findings
moderate“The provider did not record, monitor and review late visits to identify how to reduce the frequency of these. This gave the provider only limited assurance staff were always deployed effectively.”
minor“They are often late but they never call to let us know. I try to do what I can so by the time they arrive it's just a quick in and out for them.”
moderate“The relative of another person told us they had experienced 'many' missed visits. They added, 'The most significant was Christmas day and they forgot [the person].'”
safeguarding
3 findings
moderate“Two care workers did not know they can also report safeguarding concerns to statutory services and not just the provider.”
critical“the provider had not informed the Care Quality Commission of these safeguarding incidents. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.”
critical“We found records of three allegations of abuse the provider was aware of, had responded to, but had not notified the CQC of these.”
staff competency
2 findings
minor“Some recent competency assessments had not been fully completed. We discussed this with the registered manager so they could complete this process with staff.”
moderate“The provider had not assessed staff to ensure they were competent to give the medicines support being asked of them.”
consent capacity
2 findings
minor“The provider completed assessments of some people's mental capacity but did not specify what decision they considered a person may lack the capacity to make and why.”
critical“care workers regularly gave medicines to people who had not signed the provider's consent form and support with medicines was not included in their care plans.”
communication with families
2 findings
moderate“One person's care plan stated 'I have a learning disability which makes it difficult for me to communicate effectively,' and that staff should speak clearly. There was no other information.”
minor“There's not much contact from the agency or supervisor, you only really see the supervisor if they are bringing a new carer or if they are stepping in to cover.”
medication management
2 findings
critical“two of the care records we reviewed showed care workers regularly gave medicines to people who had not signed the provider's consent form and support with medicines was not included in their care plans.”
critical“The medicines administration records (MARs) we saw did not provide a clear record of the prescribed medicines people required or received.”
infection control
1 finding
moderate“Staff on site were not always able to socially distance and there was no evidence of frequent surface and equipment cleaning.”
staffing levels
1 finding
critical“the local authority support plan showed a need for two staff to support a person with all personal care tasks and moving and handling transfers...only one member of staff supported this person for three of the four visits”
cultural competency
1 finding
minor“If they could get someone who could speak my [family member's] language that would be good... Sometimes there is a language barrier and I feel I am teaching them.”
complaints handling
1 finding
critical“The local commissioning authority told us it was waiting for information from the provider on how 40 of these had been investigated and resolved.”
incident learning
1 finding
moderate“Another adult social care professional commented that some incidents kept repeating, such as missed care visits.”
end of life care
1 finding
minor“Managers told us the service avoided discussing this with people...Managers said they felt it was not the place of a domiciliary care agency to discuss end of life care.”