This assessment took place between 19 January 2025 and 11 February 2025. Lotus Home Care Wakefield is a domiciliary care agency providing personal care services to people in their own homes. During this assessment we looked at 17 quality statements. The service was providing regulated activity to 58 people at the time of the assessment. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. We found the provider had improved since the previous inspection and was no longer in breach of regulation 12. There was a culture of learning from safety events. There were effective risk assessments and care plans in place to guide staff about how to support people safely. Staff had received appropriate training and were competent in their role. Systems to monitor and improve the quality and safety of the service were robust.
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Lotus Home Care Wakefield improved from Inadequate to Requires Improvement, resolving breaches of Regulations 17 and 18, but remained in breach of Regulation 12 due to inadequate risk assessments for moving and handling, bed rails, choking, and catheter care. Governance systems were insufficiently embedded to detect these care record failures, and mixed staff feedback highlighted rota disorganisation and low morale.
Concerns (4)
criticalCare planning: “one person's care plan referred to the use of a hoist, but the risks associated with its use had not been assessed and there was no guidance for staff on how to use it.”
moderateGovernance: “Audits of care records were taking place on a monthly basis, but they failed to identify the issues we found with risk assessments at this inspection.”
moderateStaffing levels: “staff told us they worked long hours, and breaks and travel time were not accounted for.”
moderateLeadership: “The office [staff] just changes the rota whenever they feel like it and don't ask. Morale is quite low.”
Strengths
· Staff knew how to recognise and report abuse and received safeguarding training.
· Medicines administration was largely correct and staff competency was assessed through regular spot checks.
· Staff received regular supervisions, spot checks and ongoing training including the Care Certificate.
· People were supported in accordance with the Mental Capacity Act 2005 principles.
· The provider implemented a comprehensive programme of audits and used an electronic care management system to monitor calls.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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; Supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture; engaging and involving people and staffRequires improvement
Lotus Home Care Wakefield was rated Inadequate following a focused inspection triggered by complaints about care needs and late calls, with breaches found across safe care and treatment, staffing, and good governance regulations resulting in warning notices. Widespread failures included missing and contradictory risk assessments, inconsistent care staffing, missed and late visits, ineffective management oversight, and a governance culture that failed to act on concerns raised by staff and relatives.
Concerns (13)
criticalCare planning: “One person's care plan contained contradictory information. The care plan stated the person was unable to walk or weight bear but also instructed staff to prompt the person to use equipment when walking.”
criticalStaffing levels: “One relative told us their relative had 27 different care staff within a 13-day period. A member of staff said, 'Clients have no consistency of care.'”
criticalMissed or late visits: “'The carers should have been on site at 9am but hadn't turned up until 11.30am' and 'The staff I cannot fault. It's the times that are the problem.'”
criticalGovernance: “Systems to assess, monitor and improve the service were not sufficiently robust and management oversight was not evident over key aspects of the service.”
moderateRecord keeping: “Some care plans had not been scanned correctly onto the electronic system and sentences recorded on the top and bottom of pages were missing.”
moderateMedication management: “A second member of staff told us, 'There was no training with Lotus. Just training on dosette boxes and how to check it.'”
moderateSafeguarding: “Another member of staff said, 'We have to go to the office normally to raise one. I didn't know we can just raise them ourselves; it's office staff who do that.'”
moderateIncident learning: “The registered manager told us lessons learnt were shared with staff via staff meetings. However, the agendas and minutes of staff meetings we looked at did not record any of these conversations.”
moderateInfection control: “'I am not happy with [staff]. They are not wearing masks properly; it doesn't cover their noses and they don't wear aprons.'”
moderateConsent / capacity: “We saw a best interest's assessment had been completed for each person [assessed as having capacity]. This is not in line with the requirements of the Act.”
moderatePerson-centred care: “The planning of people's care was not person-centred, up-to-date or reflective of their changing needs or concerns.”
moderateCommunication with families: “A relative said, 'We've complained loads of times… don't hear anything.' One person told us, 'It's like talking to a brick wall'.”
moderateLeadership: “One member of staff told us, 'I don't feel supported. I can only get in touch with the office if I put my number as withheld. They won't answer if they know it's a carer ringing.'”
Strengths
· Staff were recruited safely with evidenced safe recruitment programme.
· Staff had received safeguarding training and knew how to recognise potential abuse.
· People and relatives spoke positively about individual care staff, describing them as outstanding and caring.
· PPE supplies were adequate and available for staff to collect from the office.
· The service worked with a range of professionals, commissioners and other organisations.
Quality-Statement breakdown (11)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongRequires 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 empowering