critical“Sometimes they [care staff] don't come on time, sometimes they are an hour or two late... Sometimes they only stay between 10 and 16 minutes, we are paying for something we are not getting (30 minutes).”
critical“For 1 person who required a 30 minute call, a staff member had only been in attendance for 4 minutes but had recorded they had provided full support.”
medication management
2 findings
critical“Some people were not given their medicines at the time they had been prescribed. This included medicine for the control of diabetes and heart conditions.”
critical“Peoples 'as required' medication protocols were inconsistent putting them at risk of receiving too much or not enough prescribed medicines.”
care planning
2 findings
critical“Care plans were not fully personalised, and information contained within them had not been reviewed and updated to reflect people's current support needs.”
critical“Care plans continued to lack information and guidance for staff to follow and some had not been reviewed and updated to reflect people's current support needs.”
safeguarding
2 findings
critical“We found multiple examples of safeguarding concerns which had not been actioned robustly. This included the impact of people being exposed to missed calls.”
critical“People continued to be placed at risk from abuse because the systems and processes in place were not robust to keep people safe.”
staffing levels
2 findings
critical“Staff rotas demonstrated the provider did not always allow them travel time between calls or more than one call was scheduled at the same time.”
critical“Staff rotas continued to demonstrate the provider did not always allow travel time between scheduled calls or more than one call was scheduled at the same time.”
governance
2 findings
critical“Although there was a system to audit aspects of the service, we found these had failed to identify people were not supported safely in a way they chose.”
critical“Care plan audits had not been completed between the period of June 2022 and March 2023. The registered manager told us they had completed these retrospectively.”
incident learning
2 findings
moderate“Incidents had not been consistently recorded or acted on... no lessons had been learnt in a timely way for issues they had been aware of for many months, such as late calls.”
moderate“Due to the lack of timeliness in the completion of audits we could not accurately assess the effectiveness of reflective practices.”
consent capacity
2 findings
moderate“For people who were unable to make their own choices, the provider had not explored or obtained evidence people making decisions on their behalf had the necessary authority to do so.”
critical“The provider had continued to fail to obtain written evidence people making decisions on their behalf had the necessary authority to do so.”
record keeping
2 findings
critical“We could not be assured the system used for staff to log in and out of calls and record their notes was safe. Staff could log in to a call when they were not in attendance.”
critical“Individual care plan audits we were provided with had been back dated from as far back as June 2022, when in fact they had all been completed in March 2023.”
communication with families
2 findings
moderate“Two people and their relatives told us some care staff members communication was limited, this was due to language barriers.”
moderate“Some staff members frequently spoke to each other in their own language, in what appeared to be raised voices. This meant the person was not aware of what was being discussed.”
person centred care
1 finding
critical“People's care and support was not always planned in partnership with them and persons close to them.”
complaints handling
1 finding
moderate“Complaints which the provider had recorded did not reflect all the complaints people and their relatives told us they had raised.”
staff competency
1 finding
moderate“A staff member we spoke with told us they did not have access to a person's care plan. They could not tell us the correct support the person required.”
staff training
1 finding
moderate“We could not be assured staff had received up to date training for epilepsy, dietary needs, and catheter care as the training matrix did not reflect this.”
leadership
1 finding
critical“The provider has a poor history of compliance and driving or sustaining improvements within the service. This is the second inspection where multiple breaches have been identified.”