moderate“The service now needs to demonstrate that these systems are working effectively, and appropriate action is taken when shortfalls are identified.”
critical“the majority of people's visits were cut short. This was frequently by ten minutes but in some cases, calls were cut short by 20 to 30 minutes. There was no explanation in the records of why this was the case.”
record keeping
2 findings
minor“This now identified areas which needed attention. For example, some care plans were overdue for review.”
moderate“There was a quality assurance system in place which included checks on care plans. However, this had not identified the shortfalls we found with regard to a lack of risk assessment and risk management care planning.”
communication with families
1 finding
minor“People told us they received quality assurance surveys from the service. However, some stated they would have liked some feedback regarding the results.”
care planning
1 finding
critical“one person had a history of falls which resulted in serious injury before District Care started providing support to them. Despite this, the service had not carried out falls risk assessment, nor was there any care planning around reducing the risk of further falls.”
consent capacity
1 finding
critical“The service was providing care to a number of people living with dementia whose capacity to make decisions had not been assessed. The registered manager demonstrated a lack of knowledge around the Mental Capacity Act.”
missed or late visits
1 finding
moderate“Records completed by staff demonstrated that people's visits were being regularly cut short and this had not been identified by the service.”
leadership
1 finding
critical“The registered manager did not demonstrate an appropriate knowledge or understanding in key subjects... They also demonstrated a poor knowledge of risk management and monitoring processes.”
incident learning
1 finding
moderate“The registered manager and provider failed to operate systems capable of identifying the shortfalls we found. Therefore, we were not assured they were able to continuously learn and improve care independently.”