critical“Quality assurance and governance systems in place were not always effective or robust. They did not identify the concerns we found at this inspection.”
minor“The response to this had not been very high. Some of the people said they had not received questionnaires.”
care planning
2 findings
moderate“Some staff did not know how to access the electronic records and as a result believed there were no care plans in place for people.”
minor“Some care plans required further information to ensure a full picture of the person's needs was accurately recorded.”
person centred care
2 findings
minor“People were not receiving rotas and were not told when different staff were going to provide their care.”
minor“[My family member] feels all at sea because different carers are coming at different times.”
medication management
1 finding
critical“Some medicines were administered with less than the required gap between doses. Medicines audits had not been completed regularly and therefore issues were not being identified or acted on.”
staff competency
1 finding
critical“The provider had failed to ensure regular competency checks were conducted to make sure they were administering medicines safely.”
record keeping
1 finding
critical“The provider had failed to ensure records were easily accessible to all staff... some people had paper care plans printed from the old system.”
missed or late visits
1 finding
moderate“The provider struggled to ensure all calls were on time and people often had different staff to support them. One person told us, 'I have issues with lateness.'”
communication with families
1 finding
moderate“People often found office staff difficult to deal with and said calls were not always returned. 'Office staff communication is not so good.'”
complaints handling
1 finding
moderate“I did complain but no one took it seriously, so I felt there was no point.”
supervision appraisal
1 finding
minor“Staff we spoke with had differing experiences of supervision and the pandemic had some impact on supervision meetings taking place.”