Agency profile · CQC 1-1763695426

C&S Makenston Special Care Service

Also known as: Bratton Place

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Provider

Mrs Esther Roselline Anzeze-Makindu

Wiltshire · South West · Active since 06/1

GoodHome-care

Overall rating

Good

safeGood

effectiveRequires improvement

caringGood

responsiveGood

well-ledGood

Last inspection

2 years ago

27/Feb/2024 - 00:00

Inspected 2 years ago

Overview Inspections (6)Findings (8)Owner-management Methodology

Inspection reports (6)

Inspection report · 2024-03-16
Framework: KLOE · 18 pages · 101 KB · PDF
Requires improvement
safe: Requires improvementeffective: Requires improvementcaring: Goodresponsive: Goodwell-led: Requires improvement
C&S Makenston Special Care Service received an overall rating of Requires Improvement for the fourth consecutive time, with a continued breach of Regulation 17 (Good governance) due to ineffective audits failing to identify medicines administration gaps and risk recording deficiencies. Despite genuine strengths in person-centred, caring practice and positive feedback from people and relatives, the provider must make sustained improvements to governance, medicines management, incident learning, and Mental Capacity Act recording.
Concerns (8)

criticalGovernance: “This was a continued breach of Regulation 17, Good governance. In their action plan dated 03/12/18 the provider stated the breach in Regulation 17, Good governance was 'achieved and ongoing'.”
criticalIncident learning: “The provider could not tell us what would happen with this information...the provider did not have an audit system in place to monitor and identify trends, when accidents or incidents happened.”
moderateMedication management: “We saw in some archived records from October to December 2018 that several medicines had not been signed for...It was not clear if the medicine was not required, was discontinued or had been missed.”
moderateMedication management: “The providers medicines audits had not identified these issues...We also saw a body map chart for one person, which had detailed two separate topical creams to be applied on the whole body area. This was incorrect.”
moderateCare planning: “Care planning audits were in place but they had not been carried out correctly. The audits identified people's needs and not what was required to improve the accuracy of the care plans themselves.”
moderateConsent / capacity: “One capacity assessment had been completed...but this had not been completed correctly or comprehensively...it was not clear from care records if people had capacity or not to consent to receive care.”
moderateStaff training: “The two senior staff required refresher training in safeguarding and medicines administration. This was last undertaken in 2016 and 2017.”
minorRecord keeping: “The hoist risk assessment did not contain a service date, when this was due or who was responsible for maintenance.”

Strengths

· People and relatives were very positive about the care received; staff described as going 'out of their way to help' and providing consistency of carer.
· Safe recruitment processes in place including references, identity checks and DBS checks for all staff.
· Service worked collaboratively with health and social care professionals including the local hospice to deliver end of life care.
· Care plans were person-centred, detailing people's preferences, likes, dislikes, abilities and independence goals.
· Staff had up-to-date safeguarding training and demonstrated good knowledge of their responsibilities.

Quality-Statement breakdown (20)

safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceRequires improvement
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 guidanceRequires improvement
caring: Ensuring people are well treated and supported; equality and diversity; involvement in decisionsGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Planning and promoting person-centred, high-quality care; duty of candourRequires improvement
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving care; working in partnership with othersRequires improvement

Single Assessment Framework · 2024-02-27

Framework: SAF · 6 pages · PDF

C & S Makenston Special Care Service is a small independent domiciliary care agency which covers the area of Trowbridge. It provides personal care to people living in their own homes in the community. At the time of our assessment 8 people were using the service. At our last inspection on 5 and 7 February 2019, we found a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider failed to have effective auditing and monitoring systems. This meant shortfalls had not been identified. In addition, the provider had not kept up to date with what was required to meet legal regulations; the provider had not displayed the CQC rating on their website. This on site assessment was in response to concerns being raised from a stakeholder organisation who had found shortfalls, during their quality assurance visit, with recruitment, medicines competency and auditing of the service provision. We found improvements had been made and lessons learned following the stakeholder assessment.