critical“Risks had either not been assessed or were not adequate in relation to choking, skin integrity, equipment, falls, malnutrition, bedrails, Parkinson's disease, multiple sclerosis, and epilepsy.”
staffing levels
1 finding
moderate“Only 71% of calls were delivered at the times scheduled... staff were often late or too early, and they were not always informed if there were going to be any changes.”
staff training
1 finding
critical“New carers I have….are not trained at all in emptying or changing both my catheter bags safely and securely…. It really is not acceptable.”
person centred care
1 finding
critical“The provider did not complete comprehensive assessments for people before they joined the service. Referral information from the local authority was used as a pre-assessment.”
governance
1 finding
critical“Although the provider had carried out audits in relation to medicines, compliance, staff files and care plans, they had not identified the issues we found at this inspection.”
incident learning
1 finding
moderate“Accidents and incidents were logged and investigated, however the follow up actions taken to protect people in the future were not always documented.”
record keeping
1 finding
moderate“Some care plans were not always signed by either the person using the service or the relative consenting to their care. Staff had not always signed and/or dated support plans.”
consent capacity
1 finding
moderate“People or their relatives' consent to care and support was not always documented.”
communication with families
1 finding
moderate“No, I haven't [been involved] and no, the [agency] don't discuss anything with me. No, we haven't seen any care plan for my [family member's] care support.”
medication management
1 finding
moderate“Although names of people's medicines were listed, the actual doses of these medicines were not always documented. People prescribed with high-risk medicines did not have appropriate risk assessment information.”