Focused inspection found the service deteriorated from Good to Requires Improvement in Safe and Well-led, with a breach of Regulation 12 due to inadequate risk assessments. Concerns also included inconsistent punctuality, mixed infection control practices, and weak communication, though medicines management, safeguarding and partnership working remained positive.
Concerns (8)
criticalCare planning: “some risk assessments contained limited information on what the potential risks were and measures in place to mitigate the risks to people.”
moderateCare planning: “there were falls protocols in place for five people at risk of falls, however these were all identical in content and not specific to people's needs.”
moderate
Missed or late visits
: “[Person] has also had a few missed calls over the months. There have been about six or so in total”
moderateStaffing levels: “Some improvement was required with the deployment of staff as we received mixed feedback from people and relatives about punctuality particularly at weekends.”
moderateInfection control: “I am slightly concerned that sometimes they [staff] used the same gloves after personal care and then proceeded to wash me. I have sometimes had to ask them to change gloves.”
moderateCommunication with families: “I would recommend them, but they really need to up their game on the communications generally and especially with staff.”
moderateGovernance: “we found improvement was needed with risk management and although the relevant policies and procedures were in place, there was mixed feedback received in relation to staff deployment and infection control.”
minorLeadership: “I don't know anyone at the office…I haven't the foggiest idea who the manager is.”
Strengths
· Safe recruitment practices with appropriate pre-employment checks completed before staff employed
· Medicines managed safely with MARs showing people received medicines as prescribed and audits in place
· Staff completed safeguarding training and people/relatives reported feeling safe
· Provider had systems to record and respond to accidents and incidents with lessons learnt shared with staff
· Registered manager understood and acted on duty of candour responsibilities
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; duty of candour; positive person-centred cultureRequires improvement
well-led: Engaging and involving people using the service, the public and staff; continuous learning and improving careRequires improvement