moderate“some of the audits had failed to identify and address the shortfalls we had identified. People's risks were not consistently well-managed”
moderate“systems in place for recording and monitoring late calls required development to ensure that people's needs had been met as planned”
moderate“the provider's quality audit system for staff supervision was not effective...three staff that had not received spot checks for four years and two staff had not received spot checks for two years.”
moderate“issues around timings of calls had not been acted on by the registered manager and it was not clear if these issues had been highlighted by audits.”
missed or late visits
4 findings
minor
“They [the staff] can be late. For example, this morning they should have come at 10.30am and it was 11.30am. They are often at least 30 minutes late.”
moderate“"They [the staff] are always late, and especially weekends." and "Staff do run late frequently."”
moderate“eight calls were not at the scheduled times on staff rota's. However, all calls were undertaken.”
moderate“eleven people told us that the timings of their calls could be better. One person said, "The times are not consistent it is all different times."”
consent capacity
2 findings
moderate“Some care documents we viewed had 'consent forms'...signed for by a relative...There was no evidence to support that the relative had the appropriate authority to sign”
moderate“people's mental capacity to consent to care had not always been assessed and reflected in their care plans in line with the MCA guidelines.”
incident learning
2 findings
moderate“care manager informed us of future plans to ensure they had systems in place to demonstrate an oversight of incidents, late calls and missed calls”
moderate“there were no effective systems in place to use the information gained to analyse trends which could prevent the likelihood of negative experiences for people recurring.”
care planning
1 finding
moderate“some moving and handling risk assessments did not refer to any risks associated with using the hoist and did not specify how to safely move the person”
record keeping
1 finding
minor“audits in place to check people's daily communication notes had not identified that on occasions words were used to describe specific tasks which were not dignified”
staff competency
1 finding
moderate“competency checks had not been undertaken to ensure staff undertook complex medical procedures safely”
complaints handling
1 finding
minor“some parts of the complaint forms had not consistently been completed to demonstrate that lessons had been learned.”
end of life care
1 finding
minor“there was little evidence from records we sampled that people had been asked for their preferences regarding their end of life wishes.”