critical“staff members had still not received up-to-date safeguarding and safety training appropriate to their role”
staffing levels
1 finding
critical“the service did not have sufficient numbers of care workers to meet people's needs. People had consistently received late or missed calls.”
missed or late visits
1 finding
critical“out of many late or missed calls that occurred between October 2017 to April 2018, only one late call had been recorded as an incident”
medication management
1 finding
critical“there was no information in their care plans or assessments to indicate why this should be the case nor were there any risk assessments in relation to administration and management of medicines”
care planning
1 finding
moderate“care needs assessments had not yet been updated to include information about people's care needs and histories”
staff training
1 finding
critical“no evidence that care workers who had commenced working at the service since September 2017 had received training to support them in their roles”
incident learning
1 finding
moderate“similar incidents had continued to occur because the service did not monitor calls on a routine basis to make sure they were completed”
governance
1 finding
critical“whilst there was an internal audit system in place, we found this to be unreliable and irrelevant because shortfalls were either not addressed or identified”
leadership
1 finding
critical“even though the provider had known since 2017, that they were in financial difficulties, in April 2018 they had still not drafted a recovery plan”
complaints handling
1 finding
moderate“No complaints had been recorded at the service, even though people had spoken about concerns”
supervision appraisal
1 finding
moderate“there was no evidence to show us that such checks were being carried out”
record keeping
1 finding
moderate“The provider did not always maintain accurate, complete and contemporaneous records relating to care delivery. We found that people's care records were not being audited.”
person centred care
1 finding
moderate“Information contained in the assessments that was relevant to people's care was not always included in their care plans.”