First inspection of Walfinch West Suffolk found breaches of Regulations 11, 12, 17 and 19 relating to consent, safe care, governance and recruitment, with insufficient risk management, MCA training and oversight. People reported kind, consistent care and timely medicines, but care planning, staff training and quality monitoring required significant improvement.
Concerns (13)
critical
Care planning
: “Care plans contained a lack of information to guide staff in managing the risks in relation to people's catheter care, falls and prevention of pressure wounds.”
criticalStaff training: “there was a lack of training for staff in meeting the needs of people with catheter care, dementia care and meeting the needs of people with complex health conditions such as Parkinson's Disease”
criticalStaff training: “staff were not provided with training in understanding their roles and responsibilities in relation to the Mental Capacity Act (2005) MCA.”
criticalConsent / capacity: “Care and risk management planning did not include an assessment of people's mental capacity. There was a lack of understanding of how MCA should be implemented in practice.”
criticalStaff competency: “One newly employed member of staff supporting people with their mobility transfers, using equipment such as a hoist told us they had not been provided with practical moving and handling training”
criticalGovernance: “Systems were either not in place or robust enough to demonstrate effective oversight and governance of the service. This was a breach of Regulation 17 (Good Governance)”
criticalOther: “Recruitment checks had not been completed on all new staff to check their suitability or competence to work with vulnerable people prior to commencing employment.”
moderateCare planning: “Moving and handling care plans were not always sufficiently detailed to guide care staff in the equipment needed and the specific support people needed with their mobility needs.”
moderateRecord keeping: “We noted the provider's training matrix recorded this member of staff as having attended this training when this was not the case.”
moderateIncident learning: “there was no system in place which would ensure oversight with management analysis to identify patterns and trends with actions to reduce the likelihood of a reoccurrence.”
moderateStaffing levels: “They [management] do their best to make sure we receive consistent carers, but there just isn't enough staff. The staff don't stay long working for the agency before they leave.”
moderateCommunication with families: “Care plans lacked detail about people's communication needs and how best to communicate with them.”
moderatePerson-centred care: “Care plans reviewed had not been updated since the service was registered with CQC and still referred to the previous owner of the service.”
Strengths
· People told us they received their medicines as prescribed.
· Staff were kind, caring and treated people with dignity and respect.
· People reported no missed calls and were kept informed if staff were running late.
· Care provided by a consistent team of staff.
· Staff wore PPE and had regular COVID-19 testing in place.
Quality-Statement breakdown (18)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies; Supporting people to live healthier lives, access healthcare servicesGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Meeting people's communication needsRequires improvement
responsive: Planning personalised care; End of life care and supportRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles; understanding quality, risks and regulatory requirements; duty of candourRequires improvement
well-led: Promoting a positive culture; Engaging people and staff; Continuous learning and improving careRequires improvement