Authentic Kare Kettering improved from Requires Improvement to Good following a focused inspection of Safe and Well-led, having remediated previous breaches of Regulations 17 and 19. The service demonstrates robust recruitment, safeguarding, medicines management, and governance systems, with minor gaps around PIR submission and staff feedback mechanisms.
Concerns (3)
minorGovernance: “The registered manager had not submitted their annual Provider Information Return (PIR) to CQC.”
minorIncident learning: “The provider informed us they would re-introduce a monthly analysis of accidents and incidents to strengthen the systems in place.”
minor
Supervision / appraisal
: “Surveys had not been completed recently by staff. The registered manager explained there was recent discussion with staff about different formats of gathering feedback.”
Strengths
· Safe recruitment processes embedded following previous breach of Regulation 19, with robust DBS and overseas police checks.
· Effective electronic rota and care planning systems providing clear guidance to staff for safe support.
· Strong safeguarding culture with staff training, referral processes, and lessons learned discussed in team meetings.
· Medicines administered safely with accurate MAR records, competency assessments, and quality audits.
· Quality assurance audits with action plans embedded into practice, improving management oversight.
Focused inspection identified two breaches of regulation relating to unsafe recruitment practices (Regulation 19) and ineffective governance systems (Regulation 17), with disorganised records and insufficient management oversight. Despite these concerns, people and relatives reported positive experiences of timely, consistent and person-centred care.
Concerns (9)
criticalGovernance: “The provider failed to ensure robust systems and processes were in place to manage the service effectively. Systems and processes in place to assess, monitor and improve the service were not effective”
criticalStaff competency: “Safe recruitment processes were not always followed. For example, there were gaps in employment histories, not all employees had references and there was no up to date photograph of each staff member.”
moderateRecord keeping: “Records management was disorganised and chaotic. For example, we found multiple systems in use... This made accessing the correct information difficult.”
moderateCare planning: “some people were at higher risk of pressure wounds or expressing distressed behaviour but the care plans in the office had not been updated in over twelve months.”
moderateMedication management: “Guidance for staff to follow when medicine was administered 'as needed' was not held on the electronic system... was not available during the inspection.”
moderateIncident learning: “Regular reviews of accidents and incidents to identify any patterns or themes and identify where lessons could be learned did not take place.”
moderateStaffing levels: “The staff rota we looked at included staff scheduled to work up to 18 calls in a day starting at 6.15am and finishing at 9.10pm.”
moderateLeadership: “The provider was not prepared or organised to facilitate a CQC inspection. Gaining access to the necessary information to complete the inspection was difficult.”
minorSupervision / appraisal: “There was no overall tracker to show when these took place, so the provider could not confirm these occurred at the frequency set out in their policy.”
Strengths
· Positive feedback from people and relatives about the timeliness, consistency and quality of care
· Staff trained in infection prevention and control with positive feedback on PPE practice
· People felt safe and safeguarding processes were followed when required
· Staff knowledgeable about identifying and reporting abuse and whistleblowing
· Engagement with partner agencies including GPs, district nurses and social workers
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, 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 empowering; engaging and involving people, public and staff