ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2022-06-25

Framework: KLOE · 17 pages · 96 KB · PDF

Requires improvement

safe: Requires improvementeffective: Requires improvementcaring: Requires improvementresponsive: Goodwell-led: Requires improvement

Ebenezer (Stone of Help) Ltd remained Requires Improvement with continued breaches of regulations 11, 12 and 17, leading to warning notices for failures around consent, behaviour-related risk management and staff competence. Governance shortfalls included missing statutory notifications, ineffective incident reviews and a medication incident where pain relief was not offered, though responsive care remained Good.

Concerns (12)

criticalConsent / capacity: “Care was not always provided with the consent of service users... they experienced restrictions on their choices and care.”
criticalStaff training: “Care staff had not received training that provided them with the skills and competence to safely manage and reduce risks to people when they expressed some behaviours”
criticalStaff competency: “Care staff providing care to service users with behaviours that could place themselves and others at risk did not always have the competence and skills to do so safely.”
criticalGovernance: “The provider had failed to ensure systems and processes were operated effectively to improve the quality and safety of care.”
criticalRecord keeping: “Statutory notifications had not been submitted for these two incidents. The provider's systems had not identified these notifications had not been sent as required.”
moderateMedication management: “one person told care staff they were in pain and they were not offered any pain relief medicine until the following day”
moderateIncident learning: “Reviews of incident forms had not identified common trends and therefore possible improvements to people's quality of care had not been explored further.”
moderateSafeguarding: “Care staff had been trained in safeguarding... However, they had not recognised when some of the people they cared for had restrictions on their freedom.”
moderateInfection control: “We were not fully assured that the provider was using PPE effectively and safely. One member of staff told us they did not wear a face mask”
moderatePerson-centred care: “Managers and leaders had not consistently developed a culture that promoted person centred outcomes, seeking people's consent and respecting people's choices.”
moderateCare planning: “Care plans and risk assessments for behaviours that could place people and others at risk of harm did not effectively assess risks and did not identify effective ways to reduce risks.”
minorSupervision / appraisal: “Random people from the office ring and give supervision.”

Strengths

· Enough staff to meet people's needs with stable staff team
· Pre-employment checks including references and DBS conducted
· People supported to attend health appointments and access healthcare professionals
· Communication needs assessed with information available in easy-read format
· People supported to follow interests, hobbies and maintain relationships

Quality-Statement breakdown (20)

safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enoughGood

Inspection reports (5)