St Anne's Community Services - Leeds DCA was rated Requires Improvement overall following inspections in November 2023, with breaches identified in governance (Regulation 17) due to ineffective audits, unreported CQC incidents, and unsafe medicines management including absent covert administration documentation. Strengths included sufficient staffing, positive relationships between staff and people supported, and effective safeguarding and infection control practices.
Concerns (7)
criticalMedication management: “Two people were given medication with food or fluids however, there was no covert administration documentation in place. A pharmacist had not been consulted.”
criticalMedication management: “Not all staff were trained in oxygen therapy. One person's administration for oxygen therapy was not correct.”
criticalGovernance: “Systems were not robust enough to demonstrate effective monitoring of the quality of the service. This was a breach of Regulation 17 (Good Governance).”
criticalIncident learning: “We identified 5 incidents which had not been reported to the CQC.”
moderateCare planning: “Risk assessments did not always include detailed information about specific risks. One person used a wheelchair, however there was no information about the use of their harness.”
moderateMissed or late visits: “Staff visits were not audited to ensure missed or later visits did not occur. People and their relatives told us visits were often cancelled or missed due to staff sickness.”
moderateRecord keeping: “Records were not always detailed or accurate. We found issues relating to records within risk assessments, medicines and quality assurance processes.”
Strengths
· Staffing levels were sufficient to meet people's needs and staff had enough time on calls.
· Safeguarding policies and procedures were in place; staff trained in safeguarding and knew how to identify and report concerns.
· Accidents and incidents were recorded, investigated, and lessons learnt were documented.
· Staff felt supported by the management team and received regular supervisions and competency assessments.
· People and relatives reported feeling safe, happy with care, and able to raise concerns.