minor“there were no dates on the risk register, for initial risk rating, target dates or review dates.”
critical“The delivery of high-quality care is not assured by the leadership, governance or culture. The service did not have an organisational risk register, or similar, to identify and mitigate risks”
incident learning
2 findings
minor“the services incident reporting tracker did not indicate when duty of candour letters was sent following an incident.”
moderate“it was unclear how lessons learned were cascaded amongst all staff following incidents”
record keeping
2 findings
minor“the copy we saw in a client's home was due to be reviewed in October 2022 and needed to be replaced with the most up to date version.”
moderate“records were not always up to date. It was unclear how important patient information was handed over when family members were providing care”
staffing levels
2 findings
critical“Substantial and frequent staff shortages posed increased risks to people who use the service. The service did not have enough staff to keep patients safe from avoidable harm”
critical“working hours in one week totalled 60 and 78 hours respectively... two staff members on the same package of care had worked 30 and 36 hour shifts respectively”
medication management
2 findings
critical“13 occasions in December where medicines were identified as 'missed' but no rationale was given, and no actions taken”
critical“asked by managers to go against original pack dispensing advice for two patients when medicines were not stored in their original packaging or liquid medicines were combined”
consent capacity
1 finding
minor“there was not a specific section for a relative or carer signature so it was unclear as to whether it was the client or relatives signature.”
missed or late visits
1 finding
critical“between 19 December 2021 and 14 February 2022 there were multiple missed shifts each week with the main reason given as staff sickness”
leadership
1 finding
critical“Leaders did not have the skills and abilities to run the service. Leaders had not taken timely action to address the need for significant improvement since our last inspection.”
staff training
1 finding
moderate“clinicians did not have any qualifications in teaching others and that the service did not have a system to record how clinicians maintained their clinical skills”
staff competency
1 finding
moderate“of the 18 members of staff enrolled on apprenticeships, eight were 20-40% behind target and four were over 40% behind target”
complaints handling
1 finding
moderate“four of the families we spoke with still told us they had not received a response or resolution to a concern raised. One family told us that they received an abusive response from managers”
communication with families
1 finding
moderate“managers could be difficult to contact and didn't always respond when queries or concerns were raised with them”
safeguarding
1 finding
moderate“service had not put into place additional safeguarding measures to protect patients and staff who were employed to care for their own family members... not measured the risk of the development of closed cultures”