moderate“Three people told us they had to cancel lunchtime visits because staff were not always able to arrive at their preferred times.”
critical“being left from 6pm until 11 am without food, being placed at risk of pressure damage from being in bed too long, time critical medication and food being late”
minor“Information about changes in rotas was not always communicated well resulting in some missed or late visits.”
governance
3 findings
minor“Two people commented about the out of hours phone not always being answered. This is an area the provider needs to improve on.”
critical
“The provider had not always reported notifiable events to the care quality commission as required.”
moderate“Although the provider completed audits, they did not have robust systems to drive continual and sustained improvements.”
staffing levels
2 findings
critical“Records showed some occasions where calls were cut short to as little as five minutes for a call intended to last 30 minutes.”
critical“The provider did not have effective staff recruitment processes to ensure that staff were suitable for their roles. There were missing references.”
safeguarding
2 findings
critical“Following the inspection we raised our concerns about the impact of late and short calls to the local authority safeguarding team.”
critical“The registered manager had not completed a risk assessment when information of concern had been highlighted in one member of staff's DBS report.”
record keeping
2 findings
moderate“Another risk assessment was inaccurately completed resulting in an incorrect level of risk being identified.”
moderate“Some of the records were not up to date which meant that information was not always kept in an accessible manner.”
end of life care
1 finding
moderate“Only people requiring end of life care had these care plans...they needed to have this information for everyone they supported.”
communication with families
1 finding
minor“Some people also commented about some of the staff not being able to communicate clearly in English...this did not promote more open and free conversations.”
staff competency
1 finding
critical“some staff we spoke with did not have good understanding of what different types of abuse were or how to report these outside of the service.”
care planning
1 finding
moderate“one person's assessment suggested staff must, 'try to support the person using pillows'. This instruction could mean something different to each member of staff”
medication management
1 finding
moderate“records of some checks were not detailed to show how the assessor had come to the judgement that the staff member was competent in this area”
supervision appraisal
1 finding
moderate“Competency checks, spot checks and feedback records on the performance of new staff were not always completed in enough detail.”
staff training
1 finding
moderate“People told us they were not confident that agency and newer staff had received sufficient training to carry out their role safely.”
leadership
1 finding
moderate“The registered manager was at the time of the inspection, the sole person responsible for planning and reviewing people's care, supporting and monitoring staff.”