Note3 Jan 2024
The service had recently increased quality assurance questionnaires to monthly frequency.
Note3 Jan 2024
Spot checks were undertaken to monitor safe staff practice and PPE adherence.
Note3 Jan 2024
Team meetings were used to promote open culture, good practice and staff communication.
Note3 Jan 2024
Daily medicines audit checks were being completed regularly and identifying some issues.
Note3 Jan 2024
A new electronic care records system was introduced, improving governance and family communication via an app.
Note3 Jan 2024
Provider was responsive to inspection feedback; management completed level 4 safeguarding training after the visit.
Note3 Jan 2024
Most people and relatives felt care was safe and staff were kind, caring and compassionate.
minorperson_centred_care3 Jan 2024
A safeguarding document stated a person 'uses all kinds of tricks' to decline care...records described them as 'little bit tricky' and said they would 'finally play victims of poor care'.
minorsupervision_appraisal3 Jan 2024
The supervision matrix did not always match up with the supervision forms in staff files.
moderatestaffing_levels3 Jan 2024
The rotas we reviewed did not give staff sufficient travel time. One staff had back-to-back visits where no travel time had been allocated, however visit locations were 30 minutes away.
moderatecommunication_with_families3 Jan 2024
Professionals told us they did not always receive a timely response to emails, and a professional noted instances where the service had failed to arrive at planned joint visits.
moderateleadership3 Jan 2024
At the time of our inspection there was not a registered manager in post. The nominated individual had submitted an application to be appointed as the registered manager.
moderateincident_learning3 Jan 2024
Systems were not operated to analyse accidents/incidents, complaints and safeguarding concerns to identify trends or themes.
moderatestaff_competency3 Jan 2024
The medication competency assessment workbook answers we reviewed were populated with internet responses. We were not assured this was an adequate process to assess staff competency.
moderatestaff_training3 Jan 2024
Staff had completed significant amounts of hours of training of many different subjects in 1 day...1 staff on 9 March 2023 had spent 15 and a half hours training.
moderaterecord_keeping3 Jan 2024
Some records were incomplete, outdated, or inaccurate...some information was inaccessible because the service was unable to access emails of a former staff member.
criticalgovernance3 Jan 2024
Audits had not been fully effective in driving improvement...care plan audits contained repeated actions without evidence of resolution.
criticalinfection_control3 Jan 2024
The service had not established or effectively implemented robust infection prevention and control procedures to effectively mitigate risk to people.
criticalcare_planning3 Jan 2024
Risk assessments were either not present, had not been updated in a timely manner, or lacked sufficient detail to help staff understand and respond to risks.
criticalmedication_management3 Jan 2024
MARs did not always represent an accurate record of all prescribed medicines and topical creams administered...1 person's MAR had been used for training/demo purposes.