moderate“Quality assurance monitoring was in place and had improved but needed further embedded with the new manager, this included following up on actions and ensuring they had been addressed fully.”
critical“Quality assurance monitoring was not effective. Audits and checks completed had not identified the issues we had during the inspection.”
communication with families
2 findings
moderate“Communication could be better. No one rings to say they will be late for visits.”
minor“other people said the opposite and had little contact with the office staff.”
staffing levels
2 findings
moderate“Staff attending care calls did not always stay for the time allocated. "They are supposed to come for half an hour, but they stay 20 minutes."”
moderate“due to sickness and staff leaving this had impacted on the business... 'Timings of calls can be an issue as I think they are short staffed.'”
missed or late visits
2 findings
moderate“People reported some calls running late and rotas often not sent out. The provider was addressing this and had employed new care coordinators.”
moderate“Care calls were not well planned, and some calls overlapped. People did not always receive their calls at the time agreed nor did staff always stay for the allocated time.”
record keeping
2 findings
minor“We found some records in need of review. A new system was being installed and the new manager was going to review all records to ensure they were up to date.”
moderate“Record management needed to be improved, including care records and medicines records.”
medication management
2 findings
minor“We found some issues with medicines records at the home of 1 person we visited, but this was addressed by the new manager.”
critical“Medicines were not always managed safely... 'As required' medicines protocols were not always in place. Topical medicines such as creams, did not always have full details of where the medicine should be applied”
leadership
2 findings
moderate“At the time of our inspection there was no registered manager in post, but a new manager had recently started in post and had started the registration process.”
moderate“We were not assured the registered manager was clear about their role nor did they have a good oversight of the running of the service.”
staff competency
1 finding
critical“Staff competency checks were not robust and often occurred in the providers office and not in people's homes.”
care planning
1 finding
critical“Risks to people and staff had not always been identified, assessed or reviewed... Some people's risk assessments were less detailed or had not been reviewed for over two years.”
staff training
1 finding
critical“Staff induction and training was not robust. Training deemed mandatory by the provider had not been completed for all staff. Staff said they had not been provided with face to face moving and handling training.”
supervision appraisal
1 finding
moderate“Staff did not feel supported. Staff supervision had not been completed as expected by the provider. Staff meetings had not occurred regularly.”
infection control
1 finding
moderate“The provider did not have robust infection control procedures in place. Staff could not tell us how to put on or take off PPE in line with current guidance.”
incident learning
1 finding
minor“lessons were learnt when things went wrong, but this was difficult to evidence because of poor record keeping.”
safeguarding
1 finding
moderate“Not all staff had completed safeguarding adults training.”