ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2022-12-30

Framework: KLOE · 17 pages · 93 KB · PDF

Requires improvement

safe: Requires improvementeffective: Requires improvementcaring: Requires improvementresponsive: Requires improvementwell-led: Requires improvement

Moorview Care (East Yorkshire and Hull) was rated Requires Improvement across all five key questions at its first inspection in October 2022, with four regulatory breaches identified covering staffing levels, consent, person-centred care, and good governance. Key failures included chronic staff shortages impacting community access and safeguarding, widespread lack of Mental Capacity Act understanding, and ineffective quality assurance systems unable to detect or remediate serious gaps in practice.

Concerns (12)

criticalStaffing levels: “The provider failed to have sufficient staff to meet people's needs, this is a breach of Regulation 18, (Staffing) of the Health and Social Care Act 2008.”
criticalConsent / capacity: “The provider failed to ensure that care and treatment was provided with the consent of the relevant person. This was a breach of Regulation 11.”
criticalGovernance: “There failed to be effective systems in place to monitor and improve the service. Records were not clear or consistent. This was a breach of Regulation 17.”
criticalPerson-centred care: “Failure to provide person-centred care was a breach of Regulation 9 (Person-centred care) of the Health and Social Care Act 2008.”
criticalSafeguarding: “Some people were placed at risk of abuse and restrictive practices due to staffing levels and unmet needs. We made referrals to the local authority safeguarding team.”
moderateCare planning: “Key information about people's behaviours and triggers were not always included within the care plans. This meant people, new staff or agency staff were put at risk.”
moderateMedication management: “Regular checks identified regular errors such as administration errors and incorrect stock levels. Lessons learnt were being considered but did not result in a reduction of errors.”
moderateInfection control: “Some staff were not wearing masks when supporting people as per current government guidance which put people at risk.”
moderateRecord keeping: “Records failed to reflect care was being delivered as directed within people's care plans. We could not be assured that people's care was being delivered in line with the care plan.”
moderateStaff competency: “Management demonstrated a lack of knowledge regarding the Mental Capacity Act. Professionals told us, for a specialist placement, the management lacked knowledge around the legislation.”
minorEnd-of-life care: “People's end of life wishes were not explored and recorded. This was an area we would expect providers to approach with people and their families.”
minorSupervision / appraisal: “Some staff told us supervisions, debriefs and competency checks were rarely completed.”

Strengths

· Recruitment was safe; appropriate checks were completed to ensure staff were of a suitable character to work with vulnerable people.
· Some staff were caring and passionate, with good knowledge of people and their daily routines.
· Processes were in place to ensure the safe administration of medicines including regular monitoring checks.
· Relatives were involved in people's care with regular reviews and meetings.
· People had been supported to maintain contact with their families.

Quality-Statement breakdown (16)

safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safely; Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionRequires improvement
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 choices; delivering care in line with standards, guidance and the law

Inspection reports (2)