critical“The governance arrangements in place to audit the quality and safety of the service were not sufficient. The systems were poor and ineffective.”
critical“Effective quality assurance and governance measures had not been fully embedded at the service.”
critical“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.”
missed or late visits
2 findings
critical“They failed to turn up on three occasions... Nobody rang to let me know. I just managed myself. I felt upset.”
moderate
“The carer is often late and changes the time”
care planning
2 findings
critical“Some people required a specialised diet to prevent them from choking, but they were given meals by staff that were unsafe for them to eat.”
moderate“some risk assessments did not always contain all the relevant control measures staff needed to provide the most effective level of care.”
record keeping
2 findings
moderate“The systems were poor and ineffective. They failed to identify the serious concerns with risk management, medication management, safeguarding, record keeping and governance.”
moderate“medical health and mental health support needs were missing from risk assessments we reviewed.”
leadership
2 findings
critical“They were however, unable to explain the failings of the service and why they had not been picked up and addressed.”
minor“some office staff were not always approachable or listened to the concerns raised by care staff.”
communication with families
2 findings
minor“I haven't spoken to anyone for a long time and not had a general review with Heart to Heart.”
moderate“there was no evidence to suggest that the feedback in relation to duration of calls and continuity of care was addressed / responded to.”
medication management
1 finding
critical“Medication administration records contained gaps indicating that some people had not received the medicines they needed to keep them safe and well.”
safeguarding
1 finding
critical“One person had unexplained bruising that had not been reported to the local safeguarding authority or CQC as required by the manager.”
incident learning
1 finding
critical“Safeguarding, accidents and other incidents that had occurred were not always properly recorded, investigated and reported.”
infection control
1 finding
moderate“The provider's policies and procedures relating to infection control and COVID 19 were brief and did not provide sufficient guidance on how the risk of COVID-19 would be managed.”
person centred care
1 finding
moderate“I used to have regular carers to shower wash me till they got whisked away... I'm a woman of 76, being washed by a girl of 18 and it's very unpleasant.”
staff competency
1 finding
moderate“Pre-employment recruitment checks were completed. However, we did highlight that some measures needed strengthening.”