Regional Care Peterborough improved from Inadequate to Requires Improvement across all five key questions, exiting Special Measures, but remained in breach of Regulations 10, 12, 16 and 17 due to ongoing gaps in medication risk assessment, dignity of care, complaints recording, and governance oversight. While recruitment, staffing, training and infection control showed sufficient improvement, medication management, care records, complaint handling and quality monitoring systems remained insufficiently effective to protect people from risk of harm.
Concerns (8)
criticalMedication management: “Medication risk assessments were not always in place for people who were supported to take their medication.”
criticalGovernance: “The governance process in place had not identified that not all complaints were being recorded.”
criticalComplaints handling: “One person had complained that they had money missing from their house. However, this was not recorded in the complaints log.”
moderateMedication management: “Not all staff completing the competency assessments had completed their training to ensure they were completing the checks appropriately.”
moderateCare planning: “Although new care plans and assessments were in place the auditing system had failed to identify missing information.”
moderatePerson-centred care: “My only comment is them [care staff] talking to each other and I can't understand a word. Washing me on the bed and talking to each other in their own language.”
moderateConsent / capacity: “One person needed an MCA and best interest decision regarding the administration of medication.”
minorRecord keeping: “Records were not always written in a way that promoted people's dignity. For example, one care plan referred to a person needing help to clean their bowel region.”
Strengths
· Staff recruitment improved with appropriate DBS checks in place; provider no longer in breach of Regulation 19.
· Missed and late calls addressed with monitoring processes implemented; feedback mainly positive about staff arriving on time.
· Staff training and induction improved; provider no longer in breach of Regulation 18.
· Staff spoke positively about management and felt supported, listened to, and able to raise concerns openly.
· Regular weekly online staff meetings held with shared minutes, enabling discussion of issues and training updates.
Quality-Statement breakdown (17)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitment; Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
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 experienceGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood
Regional Care Peterborough was rated Inadequate overall and placed in special measures due to widespread failings including missed/late calls, unsafe medicines management, poor infection control, unsafe recruitment, inadequate training/competency assessment and ineffective governance. Breaches of Regulations 9, 12, 16, 17, 18 and 19 were identified, with a warning notice served regarding COVID-19 lateral flow testing.
Concerns (15)
criticalMissed or late visits: “Some people had experienced missed and late calls, and this had put them at risk of not receiving the care and support they needed.”
criticalMedication management: “We could not be confident medicines were administered as prescribed. Medication audits had not identified all of the issues with the medicines administration records”
criticalInfection control: “Staff were not carrying out the required twice weekly lateral flow tests to prevent the spread of infection.”
criticalStaff training: “some staff had not updated their training since 2017. This placed people at risk of receiving inappropriate care.”
criticalStaff competency: “recently employed staff had not completed competency assessments before working with people on their own.”
criticalGovernance: “The registered manager had not carried out any quality monitoring or audits that may have identified the improvements needed.”
criticalLeadership: “There had been a significant lack of effective management over a considerable period of time. This had adversely impacted on the care people received”
criticalCare planning: “Care plans were contradictory and did not always contain all of the information staff needed to support people in the way they preferred.”
criticalComplaints handling: “Complaints were not always being dealt with in an appropriate or timely manner. The providers complaints process was not being followed when a complaint was received.”
criticalRecord keeping: “Record keeping was poor and records were incomplete and inaccurate. Care plans and risk assessments did not include all current information”
criticalOther: “The provider had failed to ensure that they recruited staff through robust, safe procedures. This was a breach of regulation 19 (Fit and proper persons employed)”
moderateSupervision / appraisal: “The records showed that staff had not received regular supervision or annual appraisals.”
moderatePerson-centred care: “The wording used in some care plans was disrespectful towards people and could cause confusion for staff.”
moderateEnd-of-life care: “One person being supported was receiving end of life care. However, the provider had not considered having a conversation with them about their preferences for end of life care.”
minorIncident learning: “The provider stated that there had not been any accidents or incidents in the previous 12 months.”
Strengths
· Service was working within the principles of the Mental Capacity Act
· People and relatives told us staff respected their privacy and dignity
· People had been involved in planning and reviewing their care
· Registered manager understood the duty of candour and was transparent and took on board feedback
· Staff worked with external agencies to ensure people received joined-up care
Quality-Statement breakdown (18)
safe: Preventing and controlling infectionNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
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Not rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferences; End of life care and supportNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: Meeting people's communication needsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture; duty of candour; engaging and involving people, public and staffNot rated
well-led: Working in partnership with othersNot rated