ACAH Limited improved from Requires Improvement to Good across all three inspected key questions (Safe, Effective, Well-Led) at this focused March 2022 inspection. The service demonstrated safe care delivery, robust recruitment and medicines management, effective staff training, and strong leadership, with only a minor transitional record-keeping issue noted during migration to an electronic care system.
Concerns (1)
minorRecord keeping — “It was not always easy to find the relevant details in a person's care plans and risk assessments, as both paper and electronic formats were still in use.”
Strengths
· People felt safe and reported no problems with carers; positive feedback received from all people and relatives contacted.
· Safe recruitment procedures in place including identity checks and DBS checks with sufficient staffing levels.
· Electronic medicines administration system enabled real-time oversight by the registered manager; staff trained in medicine administration.
· Staff trained in safeguarding, medication, and infection control; regular spot checks and competency checks conducted by registered manager.
· Registered manager conducted needs assessments involving people and families before care commenced.
Quality-Statement breakdown (16)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
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 care; supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; continuous learningGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
This targeted inspection of ACAH Limited was conducted to assess compliance with a Warning Notice issued for breach of Regulation 17 (Good Governance), following a previous 'Requires improvement' rating in March 2020. The provider demonstrated sufficient improvements to governance and auditing processes to satisfy the warning notice, though the overall rating remains 'Requires improvement' as only the well-led key question was examined.
Concerns (1)
criticalGovernance — “At our last inspection the provider had failed to demonstrate good governance. Action had been taken to make improvements.”
Strengths
· Provider improved auditing processes with monthly audits on care documents, supervisions, training and information relayed to staff.
· All staff had completed mandatory training; a tracker was introduced to evidence supervisions, appraisals and staff meetings.
· People and relatives were given opportunities to feedback about the quality of the service, with positive and complimentary responses received.
· Care plan records were updated in response to changes, such as when new moving and handling equipment was put in place.
· Policy changes ensured team meetings were more consistent, purposeful and accessible to staff.
Quality-Statement breakdown (1)
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInsufficient evidence to rate
ACAH Limited received an overall rating of Requires Improvement at this March 2020 inspection, with a continued breach of Regulation 17 (Good Governance) due to ineffective audit systems, out-of-date staff training, inconsistent supervision, and poor MCA documentation. Caring and responsive practice was rated Good, with people reporting kind, consistent and person-centred care from familiar staff.
Concerns (7)
criticalGovernance — “Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17”
criticalRecord keeping — “in one record there was no contact details for the person's next of kin, no daily schedule, no information around MCA and no risk assessments”
moderateStaff training — “training had not been regularly refreshed which meant the provider could not be assured staff were following best practice”
moderateSupervision / appraisal — “Staff were not receiving supervision at the intervals detailed in the supervision policy”
moderateConsent / capacity — “where a person had been deemed to lack capacity to consent to aspects of their care, there continued to be limited documentation around best interest decisions”
moderateCare planning — “Care records lacked detail as to how risks identified to people's care were mitigated, there was lack of documentation around people's mental capacity”
moderateSafeguarding — “staff training in relation to safeguarding had not been kept up to date which meant the provider could not be assured staff had the full understanding”
Strengths
· People felt safe with staff and reported kind, considerate and friendly care
· Staff arrived on time and people had consistent, familiar carers
· Medicine systems were organised with audits and competency checks in place
· Infection control practices were observed and PPE provided to staff
· Care plans were individualised, reflecting people's preferences, likes, dislikes and protected characteristics
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
ACAH Limited was rated Requires Improvement overall, with a breach of Regulation 17 (Good Governance) due to persistent failures around risk management plans, Mental Capacity Act documentation, inconsistent medicines recording, and irregular staff supervision. Caring and Responsive domains remained Good, with staff praised for compassion, consistency and flexibility.
Concerns (6)
criticalCare planning — “although the risk had been identified there was no written risk management plan in place which gave detailed instructions as to how staff needed to support people to mitigate any risk.”
criticalGovernance — “They had not fully developed quality assurance systems and audits which would help them to consistently ensure the service was running well.”
moderateRecord keeping — “there were inconsistencies in the recording of the administration of medicines on the Medicine Administration Record (MAR) sheets.”
moderateConsent / capacity — “it was unclear as to which specific decisions the person may lack capacity in...there was no documentation to support where best interest decisions needed to be made.”
moderateSupervision / appraisal — “not all staff benefitted from regular formal supervision...there were gaps and inconsistencies which needed to be addressed.”
moderateIncident learning — “there was insufficient information recorded on people's care records to direct and guide the staff of any actions they needed to take.”
Strengths
· People were treated with empathy, kindness and compassion; staff went the 'extra mile' and positive relationships had been developed.
· Safe recruitment practices were in place and staffing levels were sufficient to meet people's needs.
· Staff received regular training relevant to their role, including specialist dementia training.
· People were supported to take prescribed medicines safely and visits were timed appropriately.
· Complaints were managed effectively and responded to in a timely way.
ACAH Limited, a small domiciliary care agency in Corby, was rated Requires Improvement overall at its first inspection in November 2017, with Safe, Effective and Well-led all requiring improvement due to gaps in risk assessment documentation, MCA compliance, staff supervision and quality assurance systems. Caring and Responsive were rated Good, with people and relatives consistently praising the compassionate, flexible and person-centred approach of staff.
Concerns (7)
moderateCare planning — “after one person had fallen, their risk assessment had not been updated to reflect what had happened, and the measures that were in place to try to reduce a similar event.”
moderateRecord keeping — “eight people used bed rails to keep them safe in their beds, but the risk assessments for these and the accompanying guidance for staff was incomplete.”
moderateStaffing levels — “efforts to obtain individual references for the staff had not been forthcoming. Whilst the registered manager had considered a risk assessment...this had not been documented in each staff file.”
moderateSupervision / appraisal — “there were no formal systems in place to review staff competence and their performance on a regular basis...this was on an informal basis and lacked structure in timing and the issues discussed.”
moderateConsent / capacity — “two people that did not have the capacity to make a decision about the use of bed rails had these in place...had failed to follow the procedures and have written documentation in place regarding their use.”
moderateGovernance — “improvements were required to the quality assurance systems...medication audits were completed on a regular basis and that daily records were reviewed to ensure that care had been delivered as per people's requirements.”
moderateLeadership — “the registered manager had a full understanding of all requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”
Strengths
· People felt safe and reported consistent, timely care from regular staff members.
· Medicines were managed safely with appropriate MAR records and pharmacy liaison for blister packs.
· Staff demonstrated a highly caring, compassionate approach, frequently going above and beyond expectations.
· Care plans were person-centred and individually tailored, with personalised daily notes templates.
· Strong infection control practices with staff trained in food and hand hygiene.
Quality-Statement breakdown (25)
safe: Risk assessments adequately documented and updated following incidentsRequires improvement
safe: Safe recruitment practices evidenced in staff filesRequires improvement
safe: Safeguarding systems and staff knowledgeGood
safe: Medicines managementGood
safe: Infection prevention and controlGood
safe: Staffing levels and consistencyGood
safe: Incident and accident learningGood
effective: Staff supervision structured and documentedRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
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
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, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Working in partnership with othersGood
effective: Mental Capacity Act compliance and documentationRequires improvement
effective: Assessment of people's needs and care matchingGood
effective: Staff training and inductionGood
effective: Nutritional support and monitoringGood
effective: Healthcare needs monitoring and professional liaisonGood
caring: Caring and compassionate approach of staffGood
caring: Dignity, respect and privacyGood
caring: Promotion of independence and empowermentGood
responsive: Person-centred, individualised care planningGood
responsive: Flexibility and responsiveness to changing needsGood
responsive: Complaints handling and feedbackGood
responsive: End of life care planningRequires improvement
well-led: Knowledge and compliance with Health and Social Care Act regulationsRequires improvement
well-led: Quality assurance systems including medication audits and care plan reviewsRequires improvement
well-led: Policies and procedures up to date and reflective of practiceRequires improvement
well-led: Leadership culture, openness and staff engagementGood
well-led: Engagement with people and feedback mechanismsGood