Awesome Healthcare Solutions Limited was rated Inadequate overall following a focused inspection of Safe and Well-led, with three regulatory breaches identified covering safe care and treatment (Reg 12), safeguarding (Reg 13), and good governance (Reg 17). Key failures included unmanaged safeguarding incidents, unsafe medicines administration, missed and late care calls, and ineffective leadership and audit systems, placing the service into special measures.
Concerns (10)
criticalSafeguarding: “The provider failed to identify, investigate and report safeguarding concerns to CQC or the local authority. For example, when a relative reported an incident where service users living with dementia were locked out of their home”
criticalMedication management: “one person had a medicine prescribed to be given four times a day, but this was recorded as being administered twice daily. This meant the medicine was not being administered as prescribed.”
criticalCare planning: “A person living with epilepsy had no information in their care plan about how they presented when they had a seizure.”
criticalGovernance: “The provider had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.”
moderateMissed or late visits: “Some visits were shorter than agreed times and not always on time... Records showed some people had missed calls.”
moderateIncident learning: “Incidents had not been consistently recorded or responded to. This meant people using the service were placed at risk from potential further incidents.”
moderateLeadership: “The registered manager was not in the service on a full-time basis... they did not have oversight of the quality and safety of the service.”
moderateComplaints handling: “Complaints which the provider had recorded did not reflect all of the complaints people and their relatives told us they had raised.”
moderateCommunication with families: “Relatives told us communication with the management team was poor and this needed improvement.”
moderateRecord keeping: “Records we reviewed were incomplete or lacked detail and there was little evidence the provider used this information to monitor or improve the service.”
Strengths
· The service was working within the principles of the Mental Capacity Act 2005; staff demonstrated a good understanding of the MCA and promoted people's independence and decision-making.
· The service had effective systems for managing infection risks including those presented during the COVID-19 pandemic, with most people reporting staff used PPE effectively.
· Care plans were described as personalised.
· Staff felt there were enough staff to care for people safely.
· Some care visits were longer than scheduled where staff stayed additional time to support people.