critical“Another person who was at risk of seizures did not have this risk clearly identified in their care plans.”
moderate“a specific health care risk assessment relating to catheter care was not sufficiently detailed. This meant staff might not have access to all the information they required”
critical“One person's care plan said they needed support with their catheter. However, in this person's risk assessment... it stated, 'No catheter in use'”
governance
2 findings
critical“We requested raw data from the provider from its call monitoring system to analyse care worker visit times which they were unable to provide.”
critical
“the governance and quality assurance checks failed to identify the issues we found in relation to staff timekeeping”
record keeping
2 findings
moderate“gaps in records were not always followed up. When we raised this with the managers during the inspection. They acted promptly and immediately followed up with the individual care worker”
moderate“approximately only forty percent of peoples' paper records, including risk assessments and management plans, had been transferred onto the providers electronic care planning system”
leadership
2 findings
moderate“the registered manager was available by phone during the inspection, they were not responsible for day to day management of the service.”
moderate“The registered manager was not a visible presence at the service and there had been periods where she was not in day to day charge of the service”
incident learning
2 findings
moderate“records were not always available to evidence that this had been acted upon...the manager could not provide any evidence that this had been done.”
moderate“where there were follow up actions for the provider to do, it was not always clear if these were followed through”
missed or late visits
1 finding
critical“They say it (the visit) will be at 11am and it might not be until 2 or 3pm... Weekends, you never know who is coming”
staffing levels
1 finding
critical“a number of care packages were being refused as there were significant staffing issues, especially at weekends”
safeguarding
1 finding
critical“The provider failed to submit a notification about these in line with their regulatory responsibilities”
medication management
1 finding
moderate“The provider was not able to produce any MAR charts when we requested these during the first day of the inspection”
supervision appraisal
1 finding
moderate“staff were still not receiving regular formal supervision, in addition staff did not receive individual supervision”
complaints handling
1 finding
moderate“We were not assured that the provider was capturing and recording all the complaints that had been received”
communication with families
1 finding
moderate“we received mixed feedback from people regarding call visit times and of poor communication from the office when care workers were running late”
infection control
1 finding
minor“On our arrival at the office staff failed to ask us for evidence to show we did not have COVID-19, contrary to the provider's own infection control/COVID-19 procedures”