critical“Accurate, complete and contemporaneous records were not maintained for each person receiving support. This was a breach of regulation 17 of the HSCA 2008.”
record keeping
1 finding
moderate“We found gaps in recording in both systems meaning there was not one place where details of the planned support and the delivered support was recorded.”
missed or late visits
1 finding
critical“My mum has 4 visits a day, but they don't always stick to the times she is supposed to have, might be a couple of hours late.”
staffing levels
1 finding
moderate“Our analysis of call data showed at times there was not sufficient overlap of care workers time to ensure people that required support from 2 care workers received it.”
governance
1 finding
critical“The provider did not have appropriate systems in place to assess, monitor and improve the quality of service delivery. They were in breach of Regulation 17.”
staff competency
1 finding
critical“Gaps in employment were not explored, discrepancies between information identified at interview and on people's applications were not reviewed, and references were not validated.”
safeguarding
1 finding
critical“Risk assessments were not completed correctly and were not updated in line with changes in people's health and support needs.”
incident learning
1 finding
moderate“There were not systems in place to ensure adequate oversight and analysis of incidents and complaints to identify any themes or trends which may inform service improvement.”
person centred care
1 finding
moderate“Other people felt they were not involved in their care and had not been involved in the development of their care and support plan.”