critical“The provider could not always be assured that people were receiving their medication in a timely manner. We saw that some staff did not arrive to calls at the scheduled time.”
moderate“We saw that PRN (as and when needed) protocols were generic and needed to be more person specific.”
critical“There were multiple gaps in the recording of administration of medicines, allergies were not always recorded”
critical“a carer had chosen not to give their relative pain medication... The person was in pain and has since been admitted to hospital.”
missed or late visits
3 findings
critical
“I haven't seen the carer for three days. They're no use to me if they don't come on time.”
critical“people received multiple calls more than thirty minutes later than the planned time and many lasted less than half of the planned duration.”
critical“their family members evening call had recently been missed completely. This meant they did not receive prescribed pain relief and was left in pain.”
governance
3 findings
critical“Although the provider had a range of new audits, they could not always be assured that some scheduled calls were being met at the agreed time.”
critical“New governance systems had been implemented since the last inspection, to monitor the quality and safety of the service, but they were not effective.”
critical“Records showed that audits completed were inaccurate and contradictory.”
care planning
3 findings
moderate“some risk assessments did not contain relevant information for some individuals and were not always person centred...some information was generic and personal information was inaccurate including date of birth”
critical“Care plans viewed did not always provide clear and accurate information regarding people's needs and how staff should safely support them.”
moderate“one person's moving and handling assessment had risks recorded within it, but no risk was identified on the form.”
staffing levels
2 findings
critical“The provider could not be assured that staff were attending calls for the agreed times. We saw that some staff had calls added at short notice to their daily rota without being informed.”
critical“There was not always enough staff to ensure calls were undertaken at the planned times, or for the full duration.”
record keeping
2 findings
moderate“some daily care notes were not updated accurately with tasks marked as complete in the electronic recording system when these had been completed by relatives or completed with unrealistic time frames”
moderate“Correct codes were not always used to indicate when and why medications were not administered.”
infection control
2 findings
critical“not all staff wore masks in the office and people told us care staff did not always follow current guidance regarding the use of personal protective equipment.”
moderate“There was no evidence of staff COVID-19 testing recorded.”
staff competency
1 finding
critical“Not all staff had had their competency assessed to ensure they could administer medicines safely.”
staff training
1 finding
moderate“Not all staff had completed infection control training since the COVID-19 pandemic began.”
leadership
1 finding
critical“widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
person centred care
1 finding
moderate“When [new carers] come, they come blind; no clue what I need so I don't feel so good about them.”
complaints handling
1 finding
moderate“I no longer bother complaining as I only get empty promises.”
other
1 finding
critical“appropriate professional references were not always sought, or verbal references verified.”