Caremark (Cheshire North East) was rated Requires Improvement overall following a focused inspection in December 2023, with a breach of Regulation 17 identified due to ineffective governance, insufficient records, and incomplete MCA compliance. Strengths included a positive, open culture, safe staffing and recruitment, and person-centred flexible care delivery.
Concerns (8)
critical
Governance
: “Systems and processes to assess, monitor and improve the quality and safety of the service were not always effective. This was a breach of regulation 17”
moderateRecord keeping: “Records were not always sufficiently robust. This related to aspects of risk management, medicines records and to demonstrate full compliance with the MCA.”
moderateMedication management: “A new electronic system relating to medicines administration had been implemented. However, this needed amending to fully meet the needs of the service.”
moderateConsent / capacity: “A decision to hide medicines away to keep a person safe had been made, however, records were not robust enough to demonstrate relevant assessments had been undertaken.”
moderateLeadership: “There was no registered manager at the service. Since the last registered manager had left, the director had managed the service.”
moderateIncident learning: “3 recent issues, identified during the inspection were submitted retrospectively, this had been an oversight by the provider.”
minorSupervision / appraisal: “Systems relating to the oversight of the service had not yet been fully developed and implemented, for example in relation to the oversight of staff supervisions.”
minorStaff training: “Some staff had completed the Care Certificate and further work was being undertaken to ensure all staff had completed this.”
Strengths
· People felt safe and were positive about care; one person said 'I can't fault the care'
· Sufficient numbers of suitably trained staff recruited safely with consistent carer allocation
· Positive and open culture with approachable, responsive management
· Staff worked well with other agencies including district nurses and social workers
· Provider had created a development plan and implemented new electronic management systems
Quality-Statement breakdown (15)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse and avoidable harmGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood