critical“The provider had not ensured effective processes were in place to monitor the safety and quality of the service. This was a continued breach of Regulation 17”
critical“Robust quality assurance processes were not in place to identify and address areas for improvement.”
critical“Oversight and governance systems were not always in place to effectively monitor and assess the safety of the service.”
staffing levels
3 findings
critical“We found a significant number of their visits were half the agreed length of time. The provider was not able to evidence how they analysed this information”
critical
“one person who required two staff had care provided by one staff member on two occasions because the second staff member failed to attend”
moderate“Staff told us there was not enough staff, especially drivers, and they had calls added to their rota. This was causing them to be late for their calls.”
missed or late visits
3 findings
moderate“Staff were not always staying for the agreed length of time. We also found issues with staff punctuality and the amount of time provided to people”
critical“They do not come sometimes or they are very late. It happened frequently last weekend.”
moderate“The times that they come - can I laugh at that? They're never on time.”
record keeping
3 findings
minor“One member of staff did not have a full employment history recorded.”
moderate“Complete and accurate records were not always maintained, including records of care provided and decisions taken in relation to people's care.”
minor“Where staff supported people by applying topical creams, the areas for application were not always recorded on the person's body map.”
care planning
2 findings
moderate“Some risk assessments were not personalised and lacked clear guidance about how to keep people safe. For example, one person's epilepsy risk assessment lacked detail”
critical“Risk assessments were not always robust. The service had failed to consistently assess individual risks or act on identified risks relating to the health and safety of people”
staff training
2 findings
critical“we sat in on a staff induction session on 21 January 2020 and saw that the four attendees had been given the answers to the assessment questions in advance”
moderate“Staff completed online training to equip them with skills and knowledge but this did not always prepare them for their role.”
leadership
2 findings
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
moderate“The registered manager had not always provided clear lines of authority and effective communication about staff roles and responsibilities.”
communication with families
2 findings
moderate“There is a lack of co-ordination. We spend a lot of time chasing up, rotas are not issued and then someone unknown turns up. Communication is not good.”
moderate“Communication could be better, between the company, people and their families and staff.”
incident learning
2 findings
moderate“late or missed calls were not always thoroughly investigated to identify what went wrong so effective measures could be put in place”
moderate“The provider did not have a contingency plan in place to support the service when things went wrong.”
staff competency
1 finding
critical“newly recruited staff were being adequately trained and their knowledge checked prior to providing care and support to people. This put people at risk”
safeguarding
1 finding
critical“they had failed to record a further 22 safeguarding concerns and investigations raised by the local authority or notify the Care Quality Commission”
person centred care
1 finding
critical“Care plans were not always personalised or detailed and we found inconsistencies with some care plans.”
complaints handling
1 finding
critical“a third complaint had taken three months to be resolved... the service had failed to respond appropriately and the quality of care had not improved.”
medication management
1 finding
moderate“one MAR did not contain the month or the year and another did not contain the start date of the record... audits did not identify missing information regarding dates”
supervision appraisal
1 finding
minor“some staff had concerns about the service old us they did not always feel supported by the management team”
end of life care
1 finding
moderate“People's care plans did not contain evidence that the service explored people's preferences and choices in relation to end of life care and support.”
infection control
1 finding
critical“The provider was not following the government guidelines or their own policy and procedure in the testing of staff. Lateral Flow Tests (LFT) were being completed weekly instead of the recommended Polymerase Chain Reaction (PCR) tests.”