critical“numerous visits where staff had logged in as being at people's home for less than the agreed visit duration...15 minutes or less where the agreed visit time was 30 minutes”
governance
1 finding
critical“current auditing systems in place were not robust enough to show that the quality of the service had been assessed and improvements to the safety and quality of the services being provided”
incident learning
1 finding
critical“two separate incidents of falls...had not been recorded as incidents on the appropriate incident/accident form and there was a lack of information as to what action was taken”
record keeping
1 finding
moderate“failed to consistently maintain records in accordance with their policy...failed to maintain accurate and consistent incident/accident records and record outcomes of complaints consistently”
staff training
1 finding
moderate“some staff required refresher training as their training had recently expired...supervision notes we reviewed lacked detail”
supervision appraisal
1 finding
moderate“supervision notes...were generic and lacked detail about what was discussed during these sessions...not evident that supervision sessions were tailored to individual care workers”
staffing levels
1 finding
critical“staff were not always adequately deployed so care workers stayed the full duration of the visits”