Poppy Cottage Limited improved enough to exit Special Measures, with caring rated Good and other key questions moving from Inadequate to Requires improvement. However, continued breaches of regulations 12 (safe care), 14 (hydration) and 17 (governance) led CQC to impose conditions on the provider's registration.
Concerns (11)
critical
Governance
: “Systems or processes were not established and operated effectively to assess, monitor and improve the quality and safety of the services.”
criticalCare planning: “risks to two people's health in relation to hydration were not identified or mitigated... a daily fluid target was not identified”
criticalOther: “Fire risk assessments, emergency evacuation procedures and fire drills did not effectively identify or mitigate hazards and did not account for reduced staffing levels at night.”
moderateMedication management: “PRN protocols were not always in place and where they were, these were not always person specific to ensure effective, consistent administration of medicines.”
moderateRecord keeping: “information in people's care records were not always accurate, contemporaneous or complete. Information in different documents were not accurately cross referenced.”
moderateStaff training: “We found there were still gaps in training for existing staff across all areas. The current training matrix did not always account for staff initial training”
moderateConsent / capacity: “the decisions being assessed were not always specific and the best interest decision had not been recorded.”
moderateIncident learning: “insufficient action was taken in response to a person's hospital treatment for presumed urinary tract infection (UTI) and acute kidney injury to ensure appropriate monitoring systems were agreed”
moderatePerson-centred care: “recorded care plans did not always provide clear information about people's specific needs or support requirements... 'full support with personal care' was used without explanation”
minorCommunication with families: “people's care plans contain accurate information about identified needs and preferences... one person's care plan did not include the use of pictures, shorter words or videos”
minorSafeguarding: “one instance where a staff member had not completed the correct record for an unexplained injury, which meant this was not escalated appropriately.”
Strengths
· Caring rating improved from requires improvement to good; staff interactions warm, friendly and respectful
· Staffing levels and continuity of care had improved with reduced reliance on agency staff
· Safeguarding systems improved with appointed safeguarding lead and audit trail
· Open, positive culture with improved staff morale and supportive management
· People supported to pursue social, leisure, religious and cultural interests
Quality-Statement breakdown (18)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidance (MCA)Requires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
responsive: Planning personalised care; meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Supporting people to develop and maintain relationships and follow interestsRequires improvement
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people, the public and staff; working in partnership with othersRequires improvement