critical“One person had diabetes. Their breakfast call time varied by two hours and 17 minutes in one week during September 2020.”
critical“provider's record of rostered call time and actual call times for 21 June 2021 recorded a variance to the rostered call time on 23 of the 59 calls for this day”
moderate“staff did not always stay for the full duration of calls, times which had been assessed as required in order to ensure people's needs were met.”
medication management
3 findings
critical“one person was prescribed medicines that needed to be given four to six hours apart... medicines were given significantly earlier than the prescribed recommendation.”
critical
“Medicine administration records did not always record the exact time medicines were given... there was a risk the medicine would be less effective in managing the person's symptoms.”
moderate“We found several gaps in signatures on medicine administration records which had been audited in the last month. Audits showed medicine records had been signed off as compliant and had failed to identify these gaps.”
governance
3 findings
critical“Audits of call times were based on the time the provider had scheduled people's call for. Compliance data was inaccurate as call times varied.”
critical“The provider carried out audits and had identified shortfalls, but not enough action had been taken to address these.”
moderate“Outcomes of audits were not clearly documented and there was no clear evidence that results of quality assurance checks were used to plan improvements to the service.”
record keeping
3 findings
moderate“The provider told us they had sought advice from professionals... The providers records contradicted those held by one healthcare professional.”
moderate“Staff were not routinely recording or monitoring the food and fluid intake for this person... There was no record of the amounts of food and fluid consumed or offered.”
moderate“Timings of calls could not be confirmed by records as these were not always accurate.”
person centred care
3 findings
moderate“the provider had informed people, during the Covid-19 pandemic care calls would not be at a set time. This decision was not person centred.”
moderate“Some people did not receive care and support that was person centred because staff did not follow the care plan.”
moderate“Staff don't stay long because they've got somewhere else to go. They just want to get on to the next call. I feel I am invisible sometimes.”
leadership
2 findings
critical“There had been no registered manager in place since June 2018.”
minor“The service did not have a manager registered with the Care Quality Commission, although a manager had been appointed and was in post at the time of inspection.”
incident learning
2 findings
minor“Accidents and incidents had been reviewed by the management team... Further Improvements were needed to identify themes and trends.”
moderate“Staff did not always recognise or report risky behaviour in a timely manner so the risk could be assessed and managed appropriately.”
consent capacity
2 findings
moderate“Assessments of people's capacity to make informed decisions about their health, care and welfare were not always completed.”
moderate“Assessments of people's capacity to make informed decisions about their health, care and welfare were not sufficiently robust or recorded clearly within their assessment and care plan.”
complaints handling
2 findings
moderate“not all complaints had been formally recorded... Two people's relatives told us they had found staff at the office unhelpful when they raised concerns.”
moderate“Record keeping in relation to complaints was inconsistent. Staff had not always clearly documented that improvement had been made and sustained in response to concerns.”
communication with families
2 findings
minor“Two people's relatives told us they did not find the office staff helpful or approachable.”
moderate“A second relative felt the provider listened to their concerns and made assurances they would be looked into, but they never received a response in relation to their concerns.”
infection control
1 finding
moderate“office staff did not wear face masks in the office, despite some of the staff delivering personal care to people.”
care planning
1 finding
critical“Staff did not always follow risk assessments and care plans... staff did not follow the care plan regarding providing meals and encouraging personal hygiene and clean clothing.”
safeguarding
1 finding
moderate“Staff were not able to fully demonstrate they understood what safeguarding vulnerable adults means.”