critical“Staff told us they did not receive travel time planned into their rota which had an impact on the times of care visits, often making them late by an hour or more.”
person centred care
1 finding
critical“Care visit times were inconsistent and preferences for gender specific support or care visit times stated at reviews of care not always adhered to. This was a breach of regulation 9(1)”
governance
1 finding
critical“Systems were not effective in assessing, monitoring and mitigating the risks relating to inconsistent care visit times. This was a breach of regulation 17(1)”
medication management
1 finding
moderate“Inconsistent care visit times sometimes meant people who required their medicines at specific times or with meals were not always able to do so. People had not come to harm, but this placed them at risk.”
complaints handling
1 finding
moderate“People and relatives felt they were not listened to and were not told outcomes as a result of their feedback. One relative told us, 'The interpersonal skills of office staff and the [registered manager] need to be improved'”
supervision appraisal
1 finding
moderate“Staff told us they received supervisions and staff meetings but they felt unsupported and not listened to by the registered manager and office staff.”
incident learning
1 finding
moderate“There was a disconnect between the analysis of concerns understood by the registered manager and what people told us they were experiencing.”
staffing levels
1 finding
moderate“Staff felt pressured to cover more care visits than they had capacity to complete which impacted on care visit times or 'cutting corners.'”