NSF Health achieved an overall Good rating at this first inspection of its newly registered location, having remediated prior breaches in medicines management, record-keeping, and CQC notifications. The Well-led domain remains Requires Improvement due to inconsistent monitoring of care call times and visit punctuality, incomplete care record migration, and communication gaps with people regarding staff identity and visit schedules.
Concerns (7)
moderate
Governance
: “some calls were not logged on ECM therefore it was not clear whether the provider had fulfilled their contractual agreement. However, we cross referenced a sample of care calls and found a small percentage of calls ran late or were cut short.”
moderateMissed or late visits: “some felt staff were not always punctual and their visits were rushed.”
moderateRecord keeping: “The provider's care plan auditing had not identified if the migration of people's care records on to the new system had been fully effective.”
moderateConsent / capacity: “One person had been assessed as having variable mental capacity, however sufficient guidance was not in place to guide staff on how to support the person if their mental capacity fluctuated.”
minorCare planning: “one person's risk management plans had not been fully migrated to the new system.”
minorCommunication with families: “People and their relatives reported they were not always sure of the names of staff who supported them or the times of their care visits.”
minorPerson-centred care: “Some people shared that a language barrier between themselves and staff had sometimes been an issue.”
Strengths
· Medicines management improved since last inspection; no longer in breach of Regulation 12.
· Staff showed good awareness of people's individual needs, risks, and protected characteristics.
· People felt safe with staff; safeguarding systems and reporting processes were effective.
· Staff were suitably recruited, inducted, trained, and supported through supervision and spot checks.
· Care plans were generally detailed, personalised, and regularly reviewed.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
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: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
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 candour; Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement