moderate“The call monitoring audit summary was always the same. Medication audits had not always been acted upon by office staff to verify these had been administered correctly.”
critical“Audits to monitor and improve the service had not highlighted the concerns with late and early calls and that staff were not staying the allocated time of the visit.”
moderate“one of the care plans and accompanying risk assessment we reviewed was out of date. The registered manager had completed both the care plan and the audits of the care plans.”
record keeping
3 findings
minor“Not all staff were making full use of electronic notes as reasons for why call visits were cut short were not always recorded.”
moderate
“Staff were not always logging in and out of calls. For one person who had received 124 calls over October 2019, the call had not been logged on 24 occasions.”
moderate“two of the three staff recruitment files we viewed, did not contain the applicant's full employment history and any gaps in employment had not been explored. Three of the files did not have health declarations.”
medication management
2 findings
moderate“Staff had not queried a change in a person's medication and were not always using the appropriate codes when administering medicines.”
critical“People were not receiving some of their medicines at appropriate intervals due to the calls being early or late... missed signatures which meant we could not be assured people had received their medicines as prescribed.”
person centred care
2 findings
minor“The service had last sought formal feedback from people in 2021. Only 2 people we spoke with could recall completing a feedback form.”
critical“For one person, for 69 visits from 124, they did not receive an adequate allocation of support from the visiting staff member.”
leadership
2 findings
moderate“At the time of our inspection there was not a registered manager in post. The manager had submitted an application to register.”
critical“No action had been taken to ensure people received personal care and support from staff in a timely manner... Systems to manage the quality of the service were ineffective.”
care planning
2 findings
moderate“We saw for two people, their needs had changed, and the paper care plan no longer reflected this. We reviewed the information on the app, and the information did not reflect current needs.”
minor“One risk assessment was out of date. The risk issue identified was no longer current and the care plan needed to reflect this.”
missed or late visits
1 finding
critical“People and relatives told us staff did not always attend the planned call for care and support at the agreed time and some calls could be an hour early or two hours late.”
safeguarding
1 finding
critical“Two people told us, staff had let themselves in via the key safe and wandered around their property without permission. A third person told us, a staff member arrived one evening with a 'friend'.”
communication with families
1 finding
moderate“People overwhelmingly told us, they had to ring the office and find out why their call was late and sometimes there was no response.”
complaints handling
1 finding
moderate“People did not always know who to raise a complaint with or did not complain as they did not want to get staff into trouble.”
infection control
1 finding
moderate“We observed a staff member administer medicines, serve food and then assist with redressing a person wearing the same gloves.”
staff training
1 finding
minor“Some staff told us there was a lack of training around pressure care which included how to put on compression stockings or specialist footwear.”