critical“We pay for 30 minutes of care, neighbours have timed them [staff] and they've been there anything from 8 minutes to 20 minutes.”
minor“A small number of calls had been untimely and some call times were not agreed at a specific time. This had not impacted on their health.”
governance
2 findings
critical“Systems in place to monitor the service and quality of care people received was not consistently or reliably used.”
minor“Systems measured the quality of the care provided by the service. Some of these lacked detail about issues such as timeliness of call times.”
care planning
1 finding
critical“People did not have health specific risk assessments in place. For example, people with Diabetes and Parkinson's Disease did not have care plans and risk assessments.”
medication management
1 finding
critical“Staff were leaving medicines out for staff to administer later in the day or the next day for one person. This meant there was a risk medicines could be given incorrectly.”
safeguarding
1 finding
critical“Records were not consistently in place to evidence safeguarding concerns were always investigated and reported accordingly.”
incident learning
1 finding
moderate“The provider had failed to ensure lessons were learned when things had gone wrong. Records were not kept.”
leadership
1 finding
moderate“Staff had not been managed effectively while there was no registered manager. This meant people using the service experienced differences in how their care was provided.”
staffing levels
1 finding
moderate“The manager acknowledged there had been points when there were not enough staff to deliver safe care.”
record keeping
1 finding
critical“Not all people had care plans or risk assessments for medicines. One person required time critical medicines for Parkinson's Disease, but there was limited guidance in place.”