Watergate House (Office) is a newly registered extra care housing service rated overall Good at its first inspection, with all key questions Good except Safe which requires improvement due to medicines record-keeping errors and inconsistent incident documentation. No evidence of actual harm to people was found, and the management team had already begun implementing corrective actions.
Concerns (4)
moderate
Medication management
: “Medicine administration records were in place but there were errors on some records. This meant people were at risk of receiving an incorrect dose of medicine.”
minorMedication management: “Some records for 'as and when required' medicines were not in-line with best practice guidance.”
minorIncident learning: “Not all opportunities to learn from incidents had been taken. There had been minor incidents where action could have been taken to prevent them reoccurring.”
minorRecord keeping: “Not all lessons learnt had been documented, although the registered manager and staff demonstrated how improvements had been put in place following incidents.”
Strengths
· People were safe from the risk of abuse with robust safeguarding policies, procedures and staff training in place.
· Sufficient staff were recruited safely with all necessary pre-employment checks including DBS checks.
· Care records were person-centred, detailed and focused on promoting people's independence.
· Staff worked effectively with visiting healthcare professionals and referred people to services in a timely manner.
· People and relatives were involved in care planning and decisions about their care.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law; Supporting people to eat and drink enoughGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
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: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; duty of candourGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Continuous learning and improving careGood