moderate“some plans lacked the detail to fully mitigate the risk and give guidance to staff”
minor“some support plans for people that had transferred to the service from other providers were overdue formal care reviews.”
missed or late visits
2 findings
moderate“Weekends vary, I have an evening call and the staff rarely stay for the half an hour.”
minor“One person said staff arrived late (mainly at weekends), which caused a problem for them attending a physiotherapy appointment.”
governance
2 findings
critical“Systems to monitor the quality and performance of the service were not operated effectively to identify and maintain improvements.”
minor“The service did not have a manager registered with the Care Quality Commission (CQC). The previous registered manager had de-registered with CQC on 15 May 2019.”
record keeping
2 findings
moderate“we found gaps in information and some records not updated which had not been identified through the provider's audits.”
moderate“one file for a staff member that had transferred to the service under TUPE conditions did not have on file proof of a DBS check”
staffing levels
1 finding
moderate“I can have up to 9 calls in a morning with no travel time, it's too much.”
medication management
1 finding
critical“Issues raised in relation to medicine administration or found in medicine administration audits were not consistently addressed.”
person centred care
1 finding
moderate“The weekend call time changed without any consultation, weekends are not good.”
communication with families
1 finding
moderate“I have raised concerns with the office and been told the manager would get back to me, but they haven't.”
consent capacity
1 finding
minor“we found some of the capacity assessments had not been fully completed. This was an area the provider had identified in their own internal audits.”