moderate“Sending schedules of their visits to people was sporadic and not always accurate...care plans needed to be more person centred. The provider told us 'Care plans are ok, but we can improve.'”
moderate“one person's falls risk assessment stated they had fallen in 2019. The care plan had been reviewed in October 2020 but did not include that the person had also fallen twice in 2020.”
moderate“Another person who was at risk of choking did not have enough detail included on the measures staff should take if they had a choking incident.”
staff training
2 findings
moderate“only 72% of staff had completed Basic Life Support training and 76.9% had completed Food Hygiene training. This did not ensure staff had the knowledge and skills to support people effectively.”
moderate
“some medicine administering procedures were not completed due to staff not having yet completed the correct training.”
missed or late visits
2 findings
moderate“visits were not always on time...if they were running late, the office did not always inform people...there had been 27 complaints this year. These were generally related to late visits.”
moderate“The majority of staff reported that there had been times where people had not received their visits due to miscommunication.”
governance
2 findings
critical“The service did not have a registered manager, which was a condition of their registration.”
moderate“In September 2020 one allegation of financial abuse notification was delayed in being submitted to CQC.”
safeguarding
2 findings
critical“the provider had identified not all safeguarding incidents had been properly reported.”
critical“where two people had been involved in a safeguarding and were vulnerable to specific risks from this, there was not a risk assessment in place.”
record keeping
2 findings
minor“although information had been recorded around incidents this was not in the incident log to show the actions taken following an event.”
moderate“One staff did not have any employment references in place. It showed that attempts had been made but they had not managed to contact them.”
supervision appraisal
1 finding
moderate“One-to-one meetings with their supervisor, for support and to reflect on their work, had not routinely occurred.”
consent capacity
1 finding
moderate“records showed only 60.7% of staff had completed this. This did not ensure staff had the required understanding of consent and lawful decision making.”
leadership
1 finding
moderate“Staff told us there was a clear divide between the office, and those who provided people's support. They said communication was often poor.”
communication with families
1 finding
minor“There is no rota and no routine. If you ring up and ask for something it doesn't happen.”
infection control
1 finding
moderate“six relatives commented that at times during the year, they had seen staff remove or not wear their face masks.”