critical“Between August and October 2021, one late visit and 22 missed visits were recorded. Most missed visits were where a single member of staff attended a visit instead of the two staff required.”
moderate“'[Staff] are always 10 minutes late. They have never missed a call, but sometimes they are 2-3 hours late. They will let me know then, but it's too late by then.'”
governance
2 findings
moderate“Gaps in the provider's governance system meant that management oversight of the service was not robust and the impact on people was not clearly assessed.”
moderate“we saw no evidence this information was reviewed on a regular basis, in order to identify patterns and trends.”
staffing levels
1 finding
critical“staffing was either not sufficient or consistent enough to ensure people's needs were met in a timely manner. This placed people at risk of harm.”
care planning
1 finding
moderate“we found that these changes were not always promptly recorded in care plans and did not always contain pertinent information that had been shared by people and relatives in care review meetings.”
communication with families
1 finding
moderate“People told us they were not informed when changes were made to the rota. A relative told us, '[Staff] don't let you know about any changes. I don't like this really.'”
person centred care
1 finding
moderate“the lack of consistency in staffing at the time of our inspection meant that some people were receiving care from staff who were not known to them or familiar with their preferences.”
record keeping
1 finding
moderate“Risk management plans were variable in detail. For example, one person required the use of bed rails, but a full assessment of their use had not been completed and there was no plan in place to mitigate any identified risk.”
leadership
1 finding
minor“'I sometimes feel supported by my manager, but I personally don't feel management is approachable.'”
incident learning
1 finding
minor“It was not clear how the classification of an event was determined.”