critical“medicines were not always given as prescribed...calls taking place at much later times than scheduled or staff simply not giving them or giving at the wrong time”
critical“Care plans and risk assessments contained conflicting or inconsistent information to guide staff on the level of medication support people needed. This was unsafe.”
critical“Some people were not given their medicines at the time they had been prescribed... medicine for the control of diabetes, heart conditions and pain relief which should be administered at specific times.”
moderate“People's care records did not always identify the level of support they needed from staff with their medicines. This increased the risk of people not receiving the help they required”
missed or late visits
4 findings
critical“Records showed that some people's care calls still continued to last for less than half of the required time...some staff were recording they were in attendance of two calls at the same time”
critical“For 1 staff member, the provider had unsafely scheduled 36 care calls between 05.50 and 23.00hrs...calls were scheduled to overlap.”
critical“For one person during a month, 75 of the 264 scheduled calls which took place were 50% or below the commissioned 30 minutes length of call.”
critical“Some people and their relatives expressed frustration that they had often experienced late care calls... one person said staff had been three hours late for their lunchtime call.”
governance
4 findings
critical“provider told us they had not had good oversight of the service as they had delegated this task to a manager who had recently resigned”
critical“The providers governance systems and oversight of the service provided remained inadequate...call cramming and the working time directive not being applied.”
critical“Although there was a system to audit aspects of the service, we found these had failed to identify people were not supported safely in a way they chose.”
minor“Spot checks to confirm staff were working in line with the provider's expectations had not routinely been completed since the start of the Covid-19 pandemic”
staffing levels
4 findings
critical“people who required two staff to support them often only one member of staff attended their call...staff allocated rotas continued to not always have travel time between calls”
critical“Not enough staff members were deployed by the provider to support people...travel time and the full allocation of time staff needed to provide care was not factored into their rotas.”
critical“There was not enough staff employed and effectively deployed to meet people's needs. Staff rotas did not always allow travel time between calls or more than one call was scheduled at the same time.”
moderate“they had met with the local authority to discuss potential solutions to staffing difficulties and the punctuality of people's calls.”
record keeping
4 findings
critical“electronic records often had 'No outcome' for medicines as staff had not completed the records...inaccurate and unclear information in people's care plans”
critical“Staff had recorded they had 'administered' 1 person's medicines which conflicted with the record which also documented 'no one had opened the door'. Records were confusing and inaccurate.”
critical“Staff could log in to a call when they were not in attendance. This meant there were no assurances staff attended the calls, on time or for the correct length of time.”
minor“Some people expressed frustration over lack of access to their care records, which were held electronically.”
complaints handling
4 findings
critical“complaints people and relatives told us they had raised had not been recorded, investigated or acted on...People and their relatives had not received any outcome”
critical“Complaints were not consistently recorded and the actions that had been taken to prevent similar occurrences were not recorded. 'They never get back to you. They just don't ever sort out complaints.'”
critical“One person told us they had called one weekend over 150 times with no answer. Others told us they had given up making complaints as no-one called them back.”
moderate“one person said, 'I have complained, and nothing happened.' Another relative said, 'Staff show up extremely late... I have complained about this, but nothing has happened.'”
person centred care
4 findings
critical“people and relatives continued to tell us they had not had care reviews or been involved in their care planning”
critical“Care was not always person centred and people were not empowered to influence their care and support. People did not consistently receive care that met their needs and preferences.”
critical“All 81 people and relatives we spoke with told us they had not been involved in care reviews or care planning meetings.”
moderate“some people raised concerns about staff members' attitude and approach towards their work. One person said some staff could be rude towards them.”
infection control
4 findings
moderate“provider could not be assured staff were following safe practices adhering to the correct use and disposal of PPE...some people told us staff did not always wear PPE”
moderate“'My regular carers wear masks and gloves, the weekend ones don't. I have to chase them out if they come in and are coughing, I am very vulnerable.'”
moderate“Staff were not adhering to current guidance on the practise of lateral flow testing... the provider could not be assured staff were not attending calls when they were COVID-19 positive.”
moderate“two people said staff did not always wear masks when providing their support.”
safeguarding
3 findings
critical“multiple examples of safeguarding concerns which had not been either identified, reported or actioned robustly...including the impact of people being exposed to missed calls”
critical“Multiple safeguarding concerns had not been identified, reported, or actioned robustly. This included short and late care calls which resulted in people not receiving the correct level of support.”
critical“Three people had reported to the provider thefts of their personal items... the provider had failed to put into place or consider any steps to mitigate the risk of this happening again.”
care planning
3 findings
critical“Care plans and risk assessments did not provide staff with information on how to respond to such expressions of distress, how to de-escalate”
critical“Care plans and risk assessments continued to lack robust and clear guidance, with incorrect or conflicting information. Risk assessments continued to fail to direct staff on recognising symptoms.”
critical“Care plans were not fully personalised, and information contained within them had not been reviewed and updated to reflect people's current support needs.”
staff training
3 findings
moderate“provider's training records recorded all staff had completed practical moving and handling training, some staff told us they had never completed this”
moderate“Some staff members told us they found the monthly training 'repetitive' and 'not informative'...some staff were unable to tell us what they had learnt from certain training.”
critical“Staff had not received practical moving and handling training or had their competencies assessed, to ensure safe practices were adhered to.”
staff competency
3 findings
moderate“Although some staff members understanding and communication in English was limited the training provided was predominately on-line which was presented in English”
critical“Competency checks of staff skills were not always completed. Some staff members understanding and communication of English was limited; training continued to be predominantly online in English.”
moderate“Spot checks and competency assessments were not carried out to ensure staff were applying their skills and knowledge in the right way.”
supervision appraisal
3 findings
moderate“Spot checks to confirm staff were working in line with the provider's expectations had not routinely been completed for all staff”
moderate“The providers records demonstrated staff competency checks, to confirm staff were working in line with their expectations had not routinely been completed for all staff.”
moderate“Some staff told us they received supervision and attended meetings, but others told us they did not, records also demonstrated this.”
consent capacity
3 findings
critical“provider had still not explored or obtained evidence, that those making decisions on their behalf had the necessary legal authority to do so”
critical“The provider was not compliant with the MCA...mental capacity assessments were not decision specific. For example, 'they do not have full capacity because they have slurred speech'.”
critical“The provider did not ensure people's consent was gained prior to support being provided. This was a breach of Regulation 11.”
communication with families
3 findings
moderate“staff did not always have clear information about people's communication needs...some staff members spoke in their own language and did not communicate with them”
moderate“'If a call has been cancelled or carers are not on time the communication to inform the client is not good'...language barriers with new carers sometimes.”
moderate“People were not consistently communicated with in their preferred language. Some staff members spoke over them in their own language and did not communicate with them.”
incident learning
3 findings
critical“Incidents were not consistently audited, recorded or acted on...concerns were not always identified and appropriate actions had not always been taken”
critical“Incidents were not consistently recorded or acted on...people were at risk from potential further incidents happening, as concerns were not always identified and appropriate actions had not always been taken.”
critical“Incidents had not been consistently recorded or acted on... no record that staff discussions had taken place to consider the management of incidents.”
leadership
3 findings
critical“provider had not operated in an open and transparent way about the level of service they provide...initially told us there were 12 people using the service...we later established...at least 92”
critical“Some staff and people referred to the registered manager as a 'bully'. Some staff told us they were fearful of approaching the registered manager about their rota as they were threatened with having their hours reduced.”
moderate“The registered manager was not in the service on a full time basis... Lack of management oversight had contributed to the shortfalls identified.”
cultural competency
2 findings
moderate“Whilst it was the provider's intention to allocate staff from the same culture or who spoke the same language, this did not always happen...people remained unable to always effectively communicate with staff.”
moderate“Although some staff members understanding and communication in English was limited the training provided on-line was presented in English and alternative formats had not been provided.”