A care provider has been found to be putting vulnerable people it cares for at home ‘at risk of harm’ following an inspection.

Llyon Health Ltd, based in Sale, was inspected by the Care Quality Commission (CQC) in September when it was caring for 16 people.

The inspection team issued an enforcement warning notice after they found ‘systems had not been established to assess, monitor and mitigate risks to health, safety and welfare using the service and staff’.

“This placed people at risk of harm,” the report said. It went on to say that staff-scheduled call visits were not always well-co-ordinated and managed by the provider.

“We received mixed feedback from people and their relatives with half-expressed concerns about staff time-keeping,” it said.

One client said: “We do not have set times. It would be nice if we could be told when carers are coming, but we have never been provided with this.”

Another told the inspectors: “The carers arrive at any time, I do not have a set time. In the morning they come as late as 10am or 11.15am. I am awake, but I have to wait for carers to get me up and get my breakfast and I am hungry.”

The reports said the ‘registered manager’s oversight of scheduled calls was ineffective’.

“The rotas in place didn’t clearly record times between calls,” it said. “Therefore travel time was not always considered.

“We found the registered manager tended to book staff in for care calls days before, rather than having a clear weekly rota in place.”

However, the inspectors found no evidence that people had been harmed as a direct result of the staff deployment issue.

“But the failure had placed people at risk of harm because staff were often unable to get to their scheduled calls on time,” the report continued.

“This was a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

The inspectors said recruitment systems were ‘not in line with current legislation or the provider’s policy to keep people safe from inappropriate staff working with them’.

“This placed people at risk of potential abuse,” the report said.

Llyon Health responded immediately to these concerns during and after the inspection.

The provider confirmed that a new electronic call monitoring system would soon be introduced to improve how they coordinated and monitored staff visits.

The inspectors said the provider ‘failed to ensure the proper and safe management of people’s medicines’. “This placed people at risk of harm,” the report said.

During the visit, it came to light that one person had missed their medicines over a 24-hour period, due to staff not ordering a repeat prescription in time.

As a result, the registered manager raised a ‘safeguarding referral’.

It was said that although people’s initial assessments contained details about the level of support they required, information was not always available for people using the service to ascertain who was responsible for ordering, transporting or returning medicines to the community pharmacy.

“This meant there was a risk people could run out or have inappropriate medicines at home,” the report said.

“We identified missing signatures on one person’s medicines administration records (MAR) over a number of months. There was no evidence to suggest the service had followed this up.”

The inspection team also suggested that Llyon Health seeks advice from a reputable source about managing accidents and incidents.

But the report said systems and processes were in place to protect people from the risk of abuse and neglect.

“Relatives told us their family members felt safe with their care workers who regularly visited them at home and were confident any safeguarding issues they might raise would be taken seriously and appropriately dealt with,” it said.

Meanwhile, staff training was ‘a rushed process’ and staff competencies around their understanding of the training delivered had not been assessed, the report said.

“We received mixed feedback from people and relatives we spoke to,” it said. “While some were satisfied with the level of skill demonstrated by staff, others felt there was a lack of training.

“We found that not all staff had received appropriate training to meet people’s needs.”

Llyon Health has been contacted for comment.