YourLife (Sidcup) was rated Requires Improvement overall, with three breaches of regulation identified relating to safe care and treatment, fit and proper persons employed, and good governance. Accidents and incidents were not effectively managed, recruitment checks lacked employment history verification, care plans were not updated following changes in needs, and quality monitoring systems failed to identify these shortfalls.
Concerns (6)
criticalIncident learning: “Accidents and incidents were not always recorded and followed up and learning was not disseminated to staff.”
criticalCare planning: “one person who had recently suffered two separate episodes of fainting did not have their risk assessments and care plan updated to reflect any change in their care needs.”
criticalStaff competency: “Recruitment procedures had not been carried out to ensure that staff were of good character or have the skills and experience necessary to provide care.”
criticalGovernance: “The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.”
moderateEnd-of-life care: “People's care plans did not have people's end of life wishes and preferences documented.”
moderateRecord keeping: “employment histories were not always completed in full. The provider had not established reasons for gaps in employment”
Strengths
· Medicines were managed safely with weekly audits and no shortfalls identified
· Staff received regular training and supervisions and were considered competent by people and relatives
· People felt safe and appropriate safeguarding systems were in place
· Staff were kind, caring and treated people with dignity and respect
· Effective complaints system in place and registered manager described as approachable and supportive
Quality-Statement breakdown (21)
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough with choice in 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 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 concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; 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 staffGood
YourLife (Sidcup) was rated Requires Improvement overall, with safe and well-led both Requires Improvement due to incomplete risk assessments and the provider's failure to notify safeguarding authorities and CQC of two medicines incidents. Effective, caring and responsive were rated Good, with previous breaches of regulations 12 and 17 no longer in evidence.
Concerns (5)
criticalSafeguarding: “The provider had failed to notify the local safeguarding authorities and CQC about these incidents.”
moderateCare planning: “Risks to people were not always identified. Risk assessments were not always carried out for medicines, falls and moving and handling.”
moderateMedication management: “Risk assessments did not identify what staff should do if people refused their medicines, there was no guidance in place for staff on what they should do if this happened.”
moderateGovernance: “The provider was not fully aware of their responsibilities under current health and social care legislation.”
moderateRecord keeping: “their moving and handling risk assessment did not identify the potential risks of using these mobility aids and there was no guidance in place for staff”
Strengths
· Medicines were safely managed with weekly and monthly audits
· Sufficient numbers of suitably skilled staff deployed and no missed or late calls reported
· Appropriate recruitment checks including DBS were carried out
· Staff supported through regular training, supervisions and appraisals
· Staff completed induction in line with the Care Certificate
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
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
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effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough with choice in 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: End of life care and supportGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood