Complete Care 4 U Limited was rated Requires Improvement overall following a focused inspection in March–April 2023, with breaches identified in recruitment processes (Regulation 19) and shortfalls in medicines administration record-keeping and auditing. The service demonstrated strengths in person-centred care, safeguarding, infection control, and staff training, with very positive feedback from people and relatives.
Concerns (5)
criticalStaffing levels: “The recruitment process did not always guarantee thorough pre-employment checks had been completed.”
criticalRecord keeping: “Application forms did not provide an assurance that any gaps in employment history had been explored and a satisfactory explanation received.”
moderate
Medication management
: “one person was prescribed paracetamol for pain relief. We found on several occasions the time gap between doses had been recorded as less than the recommended 4-6 hours.”
moderateGovernance: “The provider's governance systems had not identified shortfalls in recruitment processes and medicines documentation.”
moderateRecord keeping: “Regular quality assurance checks of the MARs had not been carried out. This meant the incorrect administration of paracetamol had not been identified.”
Strengths
· People and relatives praised carers as kind, caring, respectful, reliable and professional.
· Staff were up to date with mandatory training including safeguarding and infection control.
· Staff correctly used PPE including gloves, aprons and masks when carrying out personal care.
· A recent safeguarding matter was dealt with appropriately and actions taken to learn from the incident.
· People's care records contained risk assessments and support plans covering personal and health care needs.
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood
Complete Care 4 U Limited received an overall Good rating across all five key questions at its first CQC inspection in October 2022. Minor medication recording gaps (unsigned handwritten MARs and absent 'as required' protocols) prompted recommendations but caused no harm, with all other areas demonstrating consistently good, person-centred practice.
Concerns (2)
minorMedication management: “handwritten MARs were not always signed by two members of staff to confirm dosage instructions had been transcribed accurately.”
minorMedication management: “When people were prescribed medicines on an 'as required' basis, protocols were not always in place to inform staff how and when to administer them.”
Strengths
· Robust risk assessments and strong safeguarding processes with staff trained to recognise and respond to abuse.
· Well-organised staffing deployment ensuring sufficient time to meet people's needs safely and without rushing.
· Regular needs assessments and reviews involving people and relatives, with appropriate referrals to external services.
· Person-centred support plans reflecting individual likes, dislikes, preferences, and communication needs including non-English speakers.
· Open and transparent leadership with registered manager leading by example and maintaining regular contact with people.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
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
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood