Updated 6 August 2024
We carried out our on-site assessment on 9 October 2024, off site assessment activity started on 9 September 2024 and ended on 21 October 2024. There were areas for significant improvement in Safe and Well-led, particularly with regard to the planning of care calls and governance. The service performed well against some of the statements we looked at. The registered manager and leadership team have been responsive to our feedback and continued to work with external partners to improve systems and safety. The service has previously been in breach of regulations 12 (safe care and treatment), 17 (good governance). The service was no longer in breach of regulation 12 but remained in breach of regulation 17 and was now in breach of regulation 9 (person-centred care). The provider used an electronic care records system, which was also used to plan and record call times. A sizable proportion of these call times had been significantly below the agreed duration for a number of months. There was a significant minority of people we spoke with who felt staff were either rushed, did not stay for the allotted time, and/or did not arrive on time. The provider gave assurances about their future monitoring and acting on shorter calls, late calls and otherwise poorly planned or actioned calls. Staff were committed to their role and knew people’s needs well. Governance still needed to improve. We found instances of risk assessments that needed improvement, which could have been identified and acted on with more effective auditing and governance arrangements in place.