Everycare Romford improved from Requires Improvement to Good across all key questions, having successfully addressed previous breaches of Regulations 12, 17 and 19 relating to medicines management, governance and recruitment. All five key questions were rated Good, with nine people receiving personal care and consistently positive feedback from people, relatives, staff and health and social care professionals.
Strengths
· Medicines now managed safely with no gaps in MAR sheets, regular audits, and all staff trained in medicines administration following previous breach of Regulation 12.
· Recruitment processes now robust with DBS checks, references, full employment histories and identity checks confirmed in all reviewed staff files, following previous breach of Regulation 19.
· Incidents and accidents recorded appropriately with lessons learned and follow-up actions completed by management, following previous breach of Regulation 12.
· Regular supervision now in place for all staff with a tracking matrix, following a previous recommendation to improve supervision practice.
· Quality assurance systems significantly improved including weekly feedback from people, spot checks, telephone monitoring and staff observations, following previous breach of Regulation 17.
Everycare Romford received an overall rating of Requires Improvement at its first CQC inspection, with a breach of Regulation 12 cited for unsafe risk assessment practices and inappropriate medicines management. While caring and responsive domains were rated Good — reflecting kind, personalised care and effective complaints handling — significant concerns remained around staffing levels, lack of governance audits, inconsistent supervision, and the registered manager's unsustained role due to staff shortages.
Concerns (10)
criticalMedication management: “Medicines were not always managed appropriately...no record in the care plan of why this was being administered...no medicines audits completed or spot checks made.”
criticalCare planning: “Risk assessments were scored to indicate the level of risk...however, none of the risk assessments we saw were scored.”
criticalRecord keeping: “One risk assessment had not been updated when a person's circumstances had changed requiring them to have their medicines administered by the service.”
moderateSupervision / appraisal: “One staff member told us, 'No – I didn't get any [supervision].' ...one staff had only been supervised once in six months.”
moderateStaff training: “Staff inductions were not recorded in employee's files...No staff had received appraisals as the service had been operation for less than one year.”
moderateIncident learning: “Staff seemed unaware of any changes made due to incidents or accidents...one staff member told us, 'Not really,' [when asked if lessons had been learned].”
moderateGovernance: “At the time of the inspection the registered manager told us they were not completing any audits or spot checks.”
moderateStaffing levels: “This lack of employees meant that people did not always receive the care they wanted at a time that had been agreed.”
moderateLeadership: “The registered manager did not feel supported in their role...they felt they could not complete their responsibilities as they were often required to take on caring responsibilities.”
minorMissed or late visits: “One relative told us, 'If they're ever going to be late, [staff member] rings me to inform me so I can ring my [relative].'”
Strengths
· Staff were recruited safely with robust practices including DBS checks, references and employment history verification.
· Safeguarding processes were in place and staff demonstrated good knowledge of abuse types and reporting procedures.
· Infection control policies and personal protective equipment use were in place.
· People's needs were thoroughly assessed before care commenced, with detailed and personalised care plans.
· Staff communicated effectively with each other through daily notes and care plans.
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing levelsRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard peopleGood
safe: Preventing and controlling infectionGood
effective: Staff skills, knowledge and experienceRequires improvement
effective: Assessing people's needs and choicesGood
Everycare Romford was rated Requires Improvement overall at its February 2020 inspection, with breaches of Regulations 12, 17 and 19 identified relating to unsafe medicines management, poor recruitment practices, failure to record incidents or submit safeguarding alerts, and ineffective governance. People experienced kind and caring support from staff and found the service responsive to their personal needs, but systemic failures in oversight and recording placed people at ongoing risk of harm.
Concerns (9)
criticalMedication management: “We found gaps on their Medicines Administration Record (MAR) sheets... MAR sheets were not being audited. This put people at risk of harm.”
criticalSafeguarding: “Since the previous inspection the service had not sent any safeguarding alerts to the host local authority.”
criticalIncident learning: “The service had not recorded this as an accident or an incident though it clearly was... little opportunity for learning from incidents or accidents.”
criticalGovernance: “There were no audits or quality checks of care plans or staff files... quality assurance systems or processes which may have identified the issues we found.”
criticalStaff competency: “One employee did not have a Disclosure and Barring Service (DBS) check... gaps in people's employment history, references missing from staff.”
moderateStaff training: “Staff did not receive supervision regularly. Only one staff member had received supervision and that had been seven months before the inspection.”
moderateSupervision / appraisal: “Three of the four staff files we looked at contained no spot checks, neither did they contain supervisions.”
moderateRecord keeping: “The service user guide was out of date. It had not been updated since the previous registered manager had left the service.”
moderateCommunication with families: “We found a person's daily log where staff had stated a person should see a doctor, but no action had been taken to follow this up.”
Strengths
· People told us staff were kind and caring; dignity, privacy and independence were respected.
· Risks to people were recorded with mitigating actions provided to staff.
· Staff understood infection prevention and ample PPE supplies were available.
· People's needs were assessed before care started, covering health, medicines and mental capacity.
· People were supported to eat and drink well and with their healthcare needs.
Quality-Statement breakdown (24)
safe: Using medicines safelyRequires improvement
safe: Staffing levels and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Staff providing consistent, effective, timely care within and across organisations
effective: Supporting people to eat and drink enoughGood
effective: Supporting people to live healthier lives and access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supportedGood
caring: Supporting people to express their views and be involved in decisionsGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Personalised careGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Continuous learning and improving careRequires improvement
well-led: Provider plans and promotes person-centred, high-quality careRequires improvement
well-led: Managers and staff are clear about their rolesRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Working in partnership with othersGood
Requires improvement
effective: Assessing people's needs and choicesGood
effective: Supporting people to eat and drink enoughGood
effective: Supporting people to live healthier lives and access healthcare servicesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supportedGood
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 controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to avoid social isolation and take part in activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Continuous learning and improving care; engaging and involving peopleRequires improvement