J.C. Michael Groups Ltd Bexley improved from Requires Improvement to Good across all five key questions at this November 2021 inspection, having previously breached Regulations 10, 16, 17, and 18. The service demonstrated effective staffing deployment, safe medicines management, person-centred care planning, and robust quality assurance systems.
Strengths
· Staff deployed effectively with reduced travel time between calls; no missed calls reported and punctuality praised by people and relatives.
· Robust safeguarding procedures in place with staff demonstrating clear understanding of reporting pathways.
· Medicines managed safely with MAR audits, competency assessments, and specialist CCG nurse training for complex administration.
· Care plans were person-centred, regularly reviewed, and developed with input from people, relatives, and healthcare professionals.
· Complaints handled effectively with a log, investigation process, and resolution letters evidenced.
Quality-Statement breakdown (22)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
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: Improving care quality in response to complaints or concernsGood
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: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
J.C.Michael Groups Ltd Bexley was rated Requires Improvement overall following a January 2019 inspection, having been removed from Special Measures after demonstrating progress against multiple prior regulatory breaches. Whilst improvements were confirmed across all five key questions, ratings remained at Requires Improvement for safe, responsive, and well-led because newly implemented systems had not been operational long enough to demonstrate consistent and sustained good practice.
Concerns (5)
moderateGovernance: “a safeguarding concern that was being investigated by the local authority had not been notified to the CQC”
moderateLeadership: “The service did not have a registered manager in post... The manager told us they were due to leave the service the day after we inspected.”
moderateCare planning: “systems and processes that have been implemented have not been operational for a sufficient amount of time for us to be sure of consistent and sustained good practice”
minorRecord keeping: “The log did not record the times of the calls or the names of the members of staff concerned so it was not possible to understand if these were two different instances”
minorIncident learning: “the provider's new incident and accident form was not being used by the branch. A recommendation was set to ensure that the form was put in place as soon as possible.”
Strengths
· Risks to people were being identified and appropriately assessed with updated care plans and guidelines following previous breaches.
· Medicines were managed safely with MAR audits in place and staff competency assessments completed.
· Sufficient staffing levels maintained; people reported reliable and timely care visits.
· Staff demonstrated clear understanding of safeguarding procedures and appropriate recruitment checks were in place.
· People spoke positively about caring, respectful staff who maintained privacy and dignity.
Quality-Statement breakdown (22)
safe: Risk assessment and managementRequires improvement
JC Michael Groups Ltd Bexley was rated Inadequate overall following a May 2018 inspection, with five regulatory breaches including unsafe medicines management, inadequate risk assessments, short and late visits, undignified care, and failed governance systems. The service was placed in special measures due to persistent failure to address concerns originally identified in October 2017.
Concerns (17)
criticalMedication management: “MAR sheet showed there were gaps between the 22/1/2018 and 12/2/18 but there were no details of the reasons why.”
criticalMedication management: “medicines competency assessments were not in place to ensure staff were assessed as competent to support people with their medicines.”
criticalCare planning: “It was not clear which care plans were being used to reflect the actual care people required and due to the different formats being used risks to people were also not being appropriately identified.”
criticalMissed or late visits: “One day nobody came until 7pm in the evening. I was waiting all day. It frightened me when they did come in that late as they used the key safe and just came in.”
criticalMissed or late visits: “on the 30 May, the report showed a planned visit from 10am until 10.45, however the entry showed staff arrived at 10.42 and finished at 10.51, which is less than 10 minutes for a 45 minute call.”
criticalRecord keeping: “They fill in the book as if they have finished. What if [person] was to fall or something happened during the visit. It just isn't right.”
criticalRecord keeping: “They should be here for an hour in the morning and they were here for 30 minutes but logged 50 minutes… they write 30 minutes and they log incorrect times.”
criticalGovernance: “The current systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people.”
criticalGovernance: “the provider had not sustained improvements in terms of the quality monitoring that were observed at our last inspection.”
criticalStaffing levels: “There insufficient numbers of suitable staff deployed to keep people safe and meet their needs.”
criticalPerson-centred care: “He had a very rude attitude and even threw [person's] dirty pads and dirty pyjamas all over the carpet.”
moderatePerson-centred care: “People experienced a lack of consistency in the care they received and were not aware of which staff member was coming to support them as they were not routinely informed.”
moderateStaff competency: “The new carers do not shadow experienced staff and are not properly introduced, my relative has to show the carers what to do.”
moderateSupervision / appraisal: “records showed these [spot checks] were not conducted on a regular basis. For example, in one person's care plan, the last spot check was conducted on the 23/11/17.”
moderateCommunication with families: “They listen and they say they are very sorry, but never ring you back and don't address the issue raised.”
moderateLeadership: “There was no registered manager in post.”
minorCultural competency: “They will speak in their own language to each other which makes us feel uncomfortable as it's clear they are saying things they don't want us to understand.”
Strengths
· Effective recruitment and selection procedures in place including enhanced criminal record checks, employment history verification and references.
· Safeguarding and whistleblowing procedures in place; staff trained and aware of reporting routes including escalation to local authority and CQC.
· Accidents and incidents recorded with statutory notifications completed and sent to CQC when required.
· Staff received induction including the Care Certificate, and regular training in safeguarding, medicines management and moving and handling.
· People supported with nutritional and hydration needs, with staff respecting specific dietary requirements such as vegan and gluten-free diets.
Quality-Statement breakdown (19)
safe: Risk assessmentsInadequate
safe: Medicines managementInadequate
safe: Staffing deployment and timekeepingInadequate
safe: SafeguardingGood
safe: RecruitmentGood
safe: Infection controlRequires improvement
effective: Staff training and competencyRequires improvement
JC Michael Groups Ltd Bexley was rated Requires Improvement across all five key questions at its February 2020 inspection, with regulatory breaches identified for staffing deployment (Reg 18), dignity and respect (Reg 10), complaints management (Reg 16), and governance (Reg 17). This was the third consecutive Requires Improvement rating, with the provider failing to sustain previously identified improvements around rostering, call monitoring, and quality assurance.
Concerns (9)
criticalStaffing levels: “Staff rostering records showed staff were not always given enough time to travel in-between the calls, which impacted on their ability to arrive promptly or stay the full time with people.”
criticalMissed or late visits: “Monday of this week they forgot me altogether and Tuesday and other days they have been different times and different carers. I managed with the help of my wife on Monday.”
criticalMissed or late visits: “On 3/2/2020 a person was scheduled a call from 8.35am to 9.05am. However, call monitoring records showed they were visited from 10.36am to 10.53am. Staff were late by over 2 hours.”
criticalComplaints handling: “People and their relatives were not happy with the way their complaints had been managed... I sent the manager an email complaint. I wasn't happy with their response and I'm still waiting for them to get back to me.”
criticalGovernance: “The provider's quality assurance systems were not effective; their internal monitoring and audit process's had not identified the issues we found at this inspection.”
criticalRecord keeping: “The sixth member of staff continued working, despite their residence permit to live in the United Kingdom has expired in January 2020.”
moderatePerson-centred care: “People's care was not delivered in line with their care plans. My relative needs to take tablets after food. They give after tea and help get ready for bed and my relative doesn't want that at 5.30pm.”
moderateCommunication with families: “There were no communication record for all late calls, to show the office staff had informed people when staff were running late to their scheduled home visits.”
moderatePerson-centred care: “The way staff talk to me is horrid. One of the carers even tells my loved one to hurry up. The carers have even banged their way out of the house a couple of times.”
Strengths
· People were protected from the risk of abuse with appropriate safeguarding policies, training, and cooperation with the local authority.
· Risk assessments and risk management plans were in place covering manual handling, oral care, eating and drinking, and home environment.
· Medicines were administered safely with up-to-date MAR records, PRN protocols, and regular competency checks.
· Staff understood infection control procedures and use of PPE, and had completed relevant training.
· Care plans were person-centred, containing personal history, health needs, allergies, and contact details of professionals.
Quality-Statement breakdown (24)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
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 lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
Aquaflo Care Bexley received a Good rating across all five key questions at its February 2017 inspection, having successfully remediated a prior medication management breach identified in January 2016. The service demonstrated strong person-centred care, robust governance, and effective staff support systems.
Strengths
· Medication management improvements made since previous breach, with monthly audits, MAR records, and staff competency checks in place
· Electronic call monitoring system used to ensure timely care visits, with late calls described as infrequent
· Strong safeguarding procedures with annual refresher training and clear staff understanding of reporting responsibilities
· Robust staff induction aligned to Care Certificate, with mandatory training across multiple areas and nationally recognised qualifications
· Regular supervision (3-monthly) and annual appraisals for all staff, with access to refresher and additional training
Aquaflo Care Bexley received an overall rating of Requires Improvement following an unannounced inspection in October 2017, with Well-Led rated Inadequate and a warning notice issued for breaches of Regulations 9, 12, 13 and 17. Critical failures included non-reporting of safeguarding concerns to the local authority, absence of accident/incident records since August 2016, ineffective call monitoring, and a registered manager absent from day-to-day management since April 2017 without CQC notification.
Concerns (9)
criticalSafeguarding: “The provider's procedures for reporting safeguarding concerns to the local authority were not always being followed appropriately.”
criticalGovernance: “A lack of effective quality assurance systems is a breach of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
criticalIncident learning: “We checked the providers accidents and incidents file and found there had been no accidents and incidents recorded since August 2016.”
criticalCare planning: “Care plans were not kept up to date. There was no clear guidance or information provided to staff on how people's care needs had changed.”
moderateMedication management: “The acting manager confirmed that monthly medicines audits were not being carried out.”
moderateMissed or late visits: “The provider failed to identify calls that were late, missed, early or shortened. The service did not take appropriate actions to log on a daily basis why care staff had either arrived late.”
moderateLeadership: “The registered manager had not managed the service on a day to day basis since April 2017… the provider had not done so [notified CQC].”
moderateStaff competency: “The acting manager and some staff we spoke with did not have a clear understanding of the providers safeguarding adult's procedures.”
moderateRecord keeping: “Care files were not always well organised, easy to read and complete… did not always accurately reflect people's current needs.”
Strengths
· There were sufficient staff employed to safely meet people's needs and appropriate recruitment checks took place before staff started work.
· Staff completed an induction in line with the Care Certificate and received regular supervision and annual appraisals.
· People said their privacy and dignity was respected and they were treated with kindness and care.
· People and relatives were involved in planning care needs and were aware of the complaints procedure.
· The registered manager demonstrated a clear understanding of the Mental Capacity Act 2005.
Quality-Statement breakdown (16)
safe: Risk assessments not updated following falls; no accidents and incidents recorded since August 2016Requires improvement
safe: Safeguarding concerns not reported to local authority appropriately (breach Reg 13)Requires improvement
safe: Sufficient staffing levels and appropriate recruitment checks in placeGood
safe: Medicines management: people supported to take medicines; staff trained; competency checkedGood
effective: Staff training not always effective; some staff lacked clear understanding of safeguarding proceduresRequires improvement
effective: Staff completed induction, received regular supervision and annual appraisalsGood
effective: Mental Capacity Act 2005 principles understood and applied by registered managerGood
Aquaflo Care Bexley received an overall rating of Good at its first CQC inspection in January 2016, with caring, effective, responsive and well-led domains all rated Good. A breach of Regulation 12 was identified due to incomplete medicines administration records and insufficient tiered medicines training for staff, resulting in a Requires Improvement rating for safe.
Concerns (3)
criticalMedication management: “processes to administer medicines did not always follow recommended guidance...records were in the process of being created they were not in place for each person who was supported with their medicines”
moderateMedication management: “apart from the induction training none of the staff had received any further training medicines assistance”
minorCommunication with families: “The on call system needs to be sorted out as it sometimes takes a long time to get through to someone...It's difficult to get through to the agency at weekends.”
Strengths
· People felt safe and staff were described as caring, helpful and respectful
· Appropriate recruitment checks including DBS, references and right-to-work verification were in place
· Staff completed a comprehensive induction and mandatory training programme covering safeguarding, MCA, dementia, infection control and more
· Care plans and risk assessments were person-centred and regularly updated to reflect changing needs
· A matching process ensured people were supported by staff with appropriate skills, experience and cultural background
This focused follow-up inspection found that Aquaflo Care Bexley had addressed the Regulation 17 warning notice issued after October 2017, with improved monitoring of medicines, incidents, missed calls and safeguarding records. The well-led rating improved from Inadequate to Requires Improvement as the systems, though now in place, had not been operating long enough to demonstrate sustained good practice, and no registered manager was yet in post.
Concerns (6)
criticalMedication management: “Medicines were not monitored in line with the provider's medication policy and procedure.”
criticalMissed or late visits: “The provider's systems for monitoring late or missed calls were not effective.”
criticalIncident learning: “Accidents and incidents were not being recorded and monitored.”
criticalSafeguarding: “complaints, safeguarding and missed visited were not in place, in line with the provider's policy.”
moderateGovernance: “systems for assessing and monitoring the quality and safety of the services provided have improved, but have not been operational for a sufficient amount of time for us to be sure of consistent and sustained good practice.”
moderateLeadership: “The service did not have a registered manager in place. The operations manager told us they were in the process of recruiting a new registered manager to run the service.”
Strengths
· Medication administration records (MARs) now returned to office monthly and audited; gaps investigated and acted upon.
· Accidents and incidents now recorded and audited monthly by the acting manager.
· Late and missed calls now logged; letters of apology sent and out-of-hours on-call system used correctly by staff.
· Regular staff meetings held covering CQC report, safeguarding, medicines and incident reporting; minutes circulated to absentees.
· Provider gathers people's views via satisfaction surveys, telephone monitoring calls and unannounced spot checks.
Quality-Statement breakdown (1)
well-led: Is the service well-led?Requires improvement
effective: Nutrition and hydration support
Good
effective: Access to healthcare professionalsGood
caring: Dignity and respectGood
caring: Person-centred involvement in care planningGood
caring: Information provision to people using the serviceGood
responsive: Care plan review and accuracyRequires improvement
responsive: Equality, diversity and cultural competencyRequires improvement
well-led: Quality assurance and governance systemsInadequate
well-led: Staff engagement and communicationGood
well-led: People and relative feedback mechanismsRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
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
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Meeting people's communication needsRequires improvement
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careRequires improvement
well-led: Working in partnership with othersGood
effective: People had access to healthcare professionals and dietary/nutritional needs were assessedGood
caring: People's privacy, dignity and independence respected by staffGood
caring: People and relatives involved in care planning and informed about the serviceGood
responsive: Care plans not always updated to reflect changed needs (breach Reg 9)Requires improvement
responsive: Complaints procedure in place and complaints investigated and responded to appropriatelyGood
well-led: Quality assurance systems not effective; ECM not monitored; missed/late calls not actioned (breach Reg 17, warning notice issued)Inadequate
well-led: Provider failed to notify CQC of management changes; safeguarding notifications not madeInadequate
well-led: Monthly medicines audits not carried outInadequate
well-led: Provider sought feedback via surveys, spot checks and telephone monitoring callsGood