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

criticalMedication management: “People medication plans were inaccurate and risk assessments were either absent or incomplete and did not fully consider the risks around people's medicines.”
criticalStaffing levels: “The service did not have sufficient numbers of staff in either the domiciliary or the supported living service to meet the needs of the people they supported.”
criticalSafeguarding: “Incidents were not always recognised as safeguarding and therefore correctly reported internally and externally to the local authority safeguarding team where required.”
criticalGovernance: “The provider did not have a system for the collation of incidents to identify patterns and monitor safety related information.”
criticalIncident learning: “Incidents and accidents forms were poorly completed, there was little information on how staff intervened in an incident or what techniques they used to defuse the situation.”
criticalConsent / capacity: “People's rights under the Mental Capacity Act had not always been respected and the act was not fully understood.”
moderateMissed or late visits: “Staff told us that they had regular rota changes and shortfalls meant that they were cutting visits short and arriving late to support people.”
moderateCare planning: “Care plans were inconsistent in quality and level of guidance provided to staff...plans did not contain the level of detail they needed to support people.”
moderateStaff training: “Staff supporting people with health conditions such as Parkinson's and Multiple Sclerosis did not have training in this area.”
moderatePerson-centred care: “People did not receive care that was planned to be person centred, proactive and well-co-ordinated. They were not always supported to have meaningful lives.”
moderateEnd-of-life care: “One person had been identified as being at the end of their life but there was no end of life plan in place.”
moderateRecord keeping: “Staff did not always complete the handover forms, so it was not clear who was supporting who and when. Clearer accountability was necessary.”
moderateInfection control: “Areas including food preparation areas were not always clean and staff did not always fully understand their responsibilities to support people to maintain a clean environment.”
minorComplaints handling: “There was not always a correlation between what concerns people told us that they had raised and the records at the agency.”

Quality-Statement breakdown (21)

safe: Assessing risk, safety monitoring and managementInadequate
safe: Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Preventing and controlling infectionRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires 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 care; Supporting people to live healthier livesGood
caring: Ensuring people are well treated and supported; respecting equality and diversity; Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: End of life care and supportRequires improvement
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersRequires improvement

Inspection report · 2022-12-23

Framework: KLOE · 19 pages · 103 KB · PDF

Requires improvement

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

Cephas Care Ltd improved from Inadequate to Requires Improvement across all five key questions following a new management team taking over, with previous regulatory breaches in Regulations 9, 10, 11, 12, 13, 17 and 18 all remedied. Significant work remains to embed new processes, address end-of-life care planning gaps, improve staff training in autism and mental health, resolve electronic scheduling failures causing missed domiciliary visits, and rebuild trust with relatives.

Concerns (8)

moderateMissed or late visits: “Prior to the inspection there had been issues with the scheduling of calls for people receiving a domiciliary service due to a failure of the electronic planner. This had led to some people missing their visits.”
moderateCare planning: “Information in care plans was not always easy to find as they did not all have an index or profile...End of life sections of care plans had not been completed.”
moderateEnd-of-life care: “End of life sections of care plans had not been completed but there were details of any funeral plans in place...documentation was not being stored consistently.”
moderateStaff training: “We identified continued shortfalls in staff knowledge and understanding of behaviours as an expression of anxiety and mental health.”
minorMedication management: “We did find a discrepancy for one person where the records were not accurate. The medication administration chart had not been updated when the persons medication had changed.”
minorComplaints handling: “Others were not yet confident that raising concerns would lead to change, as they had poor previous experiences. Further work is needed to improve trust with relatives.”
minorGovernance: “Further work was needed to embed some of the changes that had been made...whilst progress had been made there was still work to do to ensure processes are embedded.”
minorPerson-centred care: “There were still some examples of task based practice...objectives would benefit from being more clearly documented to ensure more consistency and measurable achievements.”

Strengths

· New management team visible and accessible to staff, relatives and people using the service, with transparent approach throughout inspection.
· Significant reduction in incidents in months preceding inspection following improved oversight and reflective learning.
· Improved safeguarding processes with staff confidence in reporting systems and whistleblowing policy.
· Staff morale had significantly improved; on-call arrangements praised by staff.
· Medications largely tallied with records; staff competency checks in place for medicines administration.

Quality-Statement breakdown (21)

safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and support; Staff working with other agenciesRequires improvement
Staff support: induction, training, skills and experience

Inspection report · 2022-07-27

Framework: KLOE · 13 pages · 85 KB · PDF

Requires improvement

safe: Requires improvementresponsive: Goodwell-led: Requires improvement

Cephas Care Ltd Domiciliary Care Agency was rated Requires Improvement overall, deteriorating from Good due to recurring medicines management failures and a breach of Regulation 17 (Good Governance). Responsive remained Good, with person-centred care, accessible communication and a clear complaints process, while medication oversight and CQC notification of safeguarding incidents required improvement.

Concerns (4)

criticalMedication management: “Medicines had not always been managed safely, because people had not always received their prescribed medicines.”
criticalGovernance: “The failure to operate effective quality assurances systems and properly assess, monitor and mitigate risks and ensure safety is a breach of regulation 17 (Good Governance)”
moderateIncident learning: “Good governance of the service had not always been achieved or the experience of lessons learnt applied across the whole service.”
moderateSafeguarding: “The service had not informed the Care Quality Commission at the time of a safeguarding incident which had been reported to the Safeguarding service.”

Strengths

· Support plans and risk assessments contained detailed person-centred information
· Staff demonstrated a good understanding of how to keep people safe from abuse
· Robust recruitment process to employ suitable staff
· People were protected from the risks associated with the spread of infection
· All people and relatives spoken with said staff were kind and caring

Quality-Statement breakdown (16)

safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood

Inspection reports (5)