Peak Care Homecare's overall rating dropped from Good to Requires Improvement following a focused inspection that identified failures in governance, medicines management, MCA compliance, staff training and supervision. A breach of Regulation 17 (Good Governance) was identified, though the provider took prompt action on issues raised during inspection.
Concerns (12)
criticalMedication management: “People did not have 'as needed' medicine protocols in place in line with best practice guidance.”
criticalGovernance: “The provider failed to ensure that effective governance systems were in place. This is a breach of regulation 17(1) (Good Governance)”
criticalGovernance: “Medicines audits had not been completed since May 2022. This meant that staff errors could have been missed.”
moderateMedication management: “Medicine administration records (MARs) we reviewed had gaps in administration, but it was not clear why.”
moderateStaff training: “Staff had not completed training in the MCA and did not always have a full understanding of the MCA.”
moderateStaff training: “seven staff members had not completed up to date training in topical medicines”
moderateSupervision / appraisal: “Most staff had not received a one to one supervision to review their practice and professional development since the new management team was put in place in January 2022.”
moderateConsent / capacity: “Three further care plans we reviewed did not include signed consent from people or legal representatives.”
moderateLeadership: “There had been no registered manager in post at the service since October 2021.”
moderateRecord keeping: “records of staff signing to confirm they had read people's care plans were not complete”
moderateIncident learning: “we also saw an incident report of a person who had a fall but there were no recorded actions to reduce further risk of falls.”
minorInfection control: “One relative told us some staff do not wear PPE.”
Strengths
· People and relatives told us they felt safe using the service and risks were assessed adequately.
· Staff were recruited safely with DBS checks and there were enough staff to cover care calls.
· Care plans were comprehensive and assessed people's specific needs, using tools like the Waterlow score.
· People were supported to maintain nutrition and hydration and to access healthcare services.
· The service was described as person-centred with an approachable management team open to feedback.
Quality-Statement breakdown (14)
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choicesNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated