Master Quality Health Care Services received an overall rating of Requires Improvement at its first inspection, with Safe and Well-led both rated Requires Improvement due to underdeveloped medicines management procedures and ineffective electronic monitoring systems that limited governance oversight. Effective, Caring and Responsive were all rated Good, with people and families speaking highly of staff conduct, flexibility and responsiveness to concerns.
Concerns (5)
moderateMedication management: “Information relating to the application of creams by staff needed further clarification. Potential risk around their use required assessing.”
moderateGovernance: “From the information available, the registered managers quality assurance monitoring systems had not always identified improvements needed.”
moderateRecord keeping: “During the inspection, records and monitoring systems were not always available, functional or effective. Issues with the electronic system prevented a full assessment.”
minorCare planning: “Care plans were person centred but required more detail.”
minorRecord keeping: “Prior to the service beginning the registered manager visited the person to discuss their needs. These visits were not recorded.”
Strengths
· People told us they felt safe when their care and support was delivered.
· Staff were described as caring, respectful and flexible by people using the service and their families.
· Sufficient numbers of staff were available to meet the needs of people, with appropriate recruitment checks in place.
· Staff received induction linked to the Care Certificate, training, supervision and spot checks.
· Family members had access to their relative's electronic care records to monitor care received.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture; Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood