critical“Care plan audits did not identify the issues we found at this inspection, for example, missing risk assessments.”
critical“There was no quality assurance framework in place that would enable the provider to measure the quality of care accurately.”
critical“One audit for a two-week period showed for one person that all visits had been met. However, daily diary records showed there were 44 late care visits and six missed ones.”
moderate“A longer period was required to ensure that systems and processes had been embedded to enable staff to provide consistently safe, effective, compassionate, and good quality care.”
critical“There was no straightforward method for the service to demonstrate to us the number of late, missed or 'clipped' calls and the action being taken in response to these.”
moderate“it was not clear why some people did not always tell the provider about these issues when they asked them for feedback”
critical“Regulation 17 HSCA RA Regulations 2014 Good governance — Medicines Administration Records (MAR) were not always completed or audited correctly.”
critical“The failure to manage rotas and monitor visits in a way that meant that staff were being consistently deployed on time...was a breach of Regulation 17.”
missed or late visits
7 findings
critical“Analysis of Teonfa's data for care visit times showed 37% of care visits were over 15 minutes late, 19% of which were over 45 minutes late.”
critical“Care visit times were inconsistent, often late by two hours or more and staff did not stay for the full length of the agreed time.”
moderate“Some people still experienced inconsistent care visit times... One relative said, 'Our only problem is that sometimes they have poor punctuality, and it's most difficult at weekends.'”
critical“Seventeen of them told us they had experienced missed calls since receiving care from the agency, whilst 24 raised concerns with persistent lateness.”
moderate“some people said there were still experiencing inconsistent care visit times which meant they were not always able to get on with their day”
moderate“The carers can arrive any time between 7:30 and 9am...rotas did not always include times for people to attend to calls”
critical“They're supposed to be here at 9am and this morning it was 9:25... On one occasion they turned up at 11:15 for a 9am call.”
care planning
6 findings
critical“Identified risks to people did not always have corresponding risk management plans in place to support staff to reduce risks to people.”
critical“During the inspection staff presented one person's care plan which contained information from another person's care plan.”
moderate“Risks were identified but measures to manage the risks were not clear and there was a lack of guidance for staff to follow.”
critical“The care plan within one person's records described them by the wrong name and gender. Therefore, we could not be certain that the information within the plan related to the person.”
moderate“care plans were adequate to capture people's individual needs, we found that often they were task-orientated and lacked personalisation”
moderate“In the seven care plans we looked at we found that five of them were receiving calls at times that did not correspond with their agreed care plan.”
record keeping
5 findings
moderate“Systems and processes to monitor the service were not always effective...the provider could not assure themselves records were accurate.”
critical“Most people had missing care plans, missing risk assessments, inaccurate records and missing medicine records. Some people had no care plans or records at all.”
critical“One person had 47 visits unaccounted for between November and January, including seven entire days.”
critical“one person's medicine was signed for throughout September, but signed for infrequently and incorrectly in subsequent months”
critical“For one person there were no daily notes in their file since June 2015. This meant that the service had no way of monitoring visits to this person.”
safeguarding
5 findings
moderate“Risks in relation to moving and handling, catheter care and falls had not been fully explored. There was limited guidance to staff to keep people safe.”
critical“Staff had failed on two occasions to recognise safeguarding concerns related to fire risks, depriving a person of their rights and medicines.”
critical“Staff did not have a good understanding of how to keep people safe or how to identify and report various forms of abuse.”
critical“In January 2017 a safeguarding was raised because a service user was found 'wandering the streets' having not had their medicines which were critical for their cognition.”
critical“Since our last inspection there had been three safeguarding referrals, but none of these had been notified to us.”
medication management
5 findings
critical“Staff told us they were crushing and administering medicines covertly without professional's agreement to determine if this was safe to do.”
critical“Staff were not aware of what the medicines were that they were administering and whether or not any of these had special instructions.”
critical“One person's medicine administration chart stated they had medicine for epilepsy and seizures, but their care plan did not mention anything about this.”
critical“Missed medication on the 21 January 2017 resulted in them having a seizure and being admitted to hospital.”
critical“MAR charts were not always completed correctly...errors and omissions were not always identified or acted upon”
complaints handling
5 findings
minor“Some people felt they could not go to the provider to complain due to concerns about the response and would instead speak to a social worker.”
moderate“People told us they did not feel they were listened to and no action was taken to resolve their complaints.”
moderate“A response and outcome was not present in any of the complaints we looked at.”
moderate“Other people said improvements made after they complained had not always been sustained. The provider needed to improve people's experiences of this.”
moderate“Four people had made comments regarding the lateness of care staff, but no action was taken to address these concerns.”
consent capacity
4 findings
critical“Staff did not understand the principles of the MCA or recognise restrictive practices. People had experienced unlawful restrictions.”
moderate“They also struggled to understand safeguarding or the principles of the Mental Capacity Act and how to ensure consent was sought.”
critical“Five of the care plans we looked at had not been signed to indicate the person's consent to the care had been given.”
moderate“two members of staff were not certain of what the act was or how it applied to people using the service”
staff competency
4 findings
moderate“Staff did not have a good understanding of the conditions people were diagnosed with and how best to support them.”
moderate“Staff did not understand the various conditions that people they supported had or how this impacted them. For example, diabetes and dementia.”
moderate“The service had accepted care packages for people with a variety of complex needs including learning disabilities, diabetes and epilepsy but did not provide any specialised training.”
critical“Regulation 19 HSCA RA Regulations 2014 — References were not always validated and DBS checks were not always carried out appropriately.”
incident learning
4 findings
moderate“Lessons learnt focused more on telling staff what they should or should not do but not enabling reflection on what went wrong.”
moderate“These had been shared amongst the staff team...However, these did not always translate to the care experience and people told us they had not seen improvements.”
moderate“We asked to see accident and incident forms to see how the service were responding to any incidents that occurred, however none had been logged since 2015.”
moderate“Action was not being taken at the time when care staff failed to attend calls... the service could not take sufficiently prompt action to reduce the risk of recurrence.”
communication with families
4 findings
moderate“Most people and relatives told us they thought communication from office staff and management needed to be improved.”
minor“People felt communication from office staff could be better.”
minor“Some people also commented about some of the staff not being able to communicate clearly in English...this did not promote free conversations that would help them build relationships”
minor“I've had no phone numbers or anything so I wouldn't know who to speak to if I wanted to.”
staff training
3 findings
critical“The training programme set out meant staff had to cover 11 subjects within one day. This did not give sufficient time to support staff.”
critical“The service still did not provide training for staff to understand the Mental Capacity Act (2005).”
moderate“Staff did not always receive training in the mental capacity act and did not always understand how it applied in practice.”
person centred care
3 findings
moderate“People were not all provided with culturally appropriate care. Some people felt their preferences and needs were not always understood by staff.”
moderate“People's care could not be person centred in practice due to the inconsistency in care visit times.”
moderate“Care plans included outcomes such as 'I would like to remain clean and presentable' which were generic in nature and often repeated across multiple care plans.”
supervision appraisal
2 findings
moderate“Supervision notes contained identical wording across different staff and different supervisors. There was no evidence of competency assessments.”
moderate“I've had one supervision since I joined. I haven't had a performance review yet but I'll have one soon.”
infection control
2 findings
moderate“The registered manager and staff were not aware of the current government guidance in relation to the use of PPE and the prevention of spreading infections.”
minor“People told us staff did not always wear PPE correctly in practice.”
cultural competency
2 findings
moderate“Some people felt their preferences and needs were not always understood by staff where English was not their first language.”
minor“Some [staff] don't speak English. Some don't speak at all. It can be hard to explain to them what needs to be done.”
end of life care
2 findings
moderate“People's wishes for the support they would like in the event of becoming ill or at the end of their life had not always been discussed or recorded.”
minor“Only people requiring end of life care had this information in their care plans...most had not discussed how they would wanted to be supported at the end of their lives”
leadership
2 findings
critical“The registered manager did not have the skills and knowledge to perform their role and have a clear oversight of the service.”
moderate“Following the first day of our inspection we were told that the new manager had resigned and that the provider would now apply to become the registered manager.”
staffing levels
2 findings
minor“Some people were also concerned that constant changes in staff put them at risk of inconsistent care.”
critical“The service was commissioned to deliver 812 hours of a support a week. This would have required each member of the care staff to work a 40 hour week with no allowance for holidays or sickness.”