critical“Not all staff who administered people's medication had achieved up to date medication training and care plans did not clearly and accurately document the level of medicine support required.”
critical“Neither the risk assessment nor Medication Administration Record [MAR] provided guidance for staff detailing how much thickening agent was to be used.”
critical“Staff had received medication training but had not had their competency assessed through direct observation to ensure they were administering medicines safely.”
care planning
2 findings
critical“Risks for people were not identified, recorded and mitigated in relation to their care and support needs.”
moderate
“not all risks for people were identified and recorded... Risks relating to specific health conditions had not been considered or recorded.”
missed or late visits
2 findings
moderate“They [staff] are all over the place... the biggest problem is that staff are not on time.”
moderate“there was negative feedback about staff's punctuality and people were not routinely notified if staff were running late.”
staff training
2 findings
critical“Not all staff employed at the service had attained up to date mandatory or specialist training relating to the needs of the people they supported.”
moderate“Staff had not completed an assessment to demonstrate their knowledge and competence at the end of each training session.”
staff competency
2 findings
moderate“Staff did not have up to date training... not all staff had received formal supervision.”
critical“Recruitment checks had not been completed on new staff to check their suitability or competence to work with vulnerable people prior to commencing employment”
supervision appraisal
2 findings
moderate“Not all staff had received formal supervision and it was unclear from the records viewed if staff had received regular 'spot visits'.”
moderate“Not all staff had received regular supervision or 'spot check' visits.”
governance
2 findings
critical“Governance arrangements had not identified staffing shortfalls... lessons were not learned as failings identified had not been addressed by the provider.”
critical“The quality assurance and governance arrangements in place were not effective in identifying shortfalls in the service.”
record keeping
2 findings
moderate“The registered manager failed to keep accurate and up to date records for people using the service and staff.”
moderate“Most areas of the document were not completed and remained blank. This did not provide assurance that the registered manager had clear oversight of the service”
complaints handling
2 findings
moderate“Not all complaints and concerns raised via the domiciliary care agency recorded information detailing the actions taken and if the complaint was resolved.”
minor“details of the investigation and action taken were not robust and required improvement.”
staffing levels
1 finding
critical“Out of 4100 care calls delivered, 1165 calls were more than 45 minutes late... 1678 calls had no travel time included.”
incident learning
1 finding
critical“There was no evidence of continuous learning and improvement. Lessons were not learned as failings identified had not been addressed by the provider.”
leadership
1 finding
critical“The registered manager did not understand the importance and responsibilities of their role to ensure compliance with regulatory requirements.”
safeguarding
1 finding
critical“Recruitment practices remained unsafe... DBS checks were not completed or received until after staff had commenced in post.”
consent capacity
1 finding
moderate“People's capacity and ability to make decisions was not assessed and recorded.”