DCK Care Ltd improved significantly since its previous Inadequate rating, exiting Special Measures with an overall Good rating, though Safe remains Requires Improvement due to unclear care plans, risk assessments lacking detail, and gaps in medicine administration records. Well-led was rated Good with effective quality monitoring, safe recruitment, improved staff training, and a person-centred culture, despite some residual concerns about communication with families.
Concerns (6)
moderateCare planning: “A care plan we reviewed for a person at risk of choking was found to be lacking in detail to ensure this risk was fully minimised.”
moderateCare planning: “Another care plan we reviewed stated a person was at risk of falls, however the risk assessment required greater detail to ensure this risk was fully reduced.”
moderateMedication management: “one care plan we reviewed stated a person had a 'covert certificate in place', however their care plan did not detail how medicines should be given covertly.”
moderateMedication management: “we found inconsistencies in recording. For example, we found a small number of gaps on medicine administration records.”
moderateRecord keeping: “However, we found some care plans to be unclear.”
minorCommunication with families: “The communication has really improved but there is still room for improvement in that aspect.”
Strengths
· Significant improvements made; service no longer in Special Measures and overall rating moved from Inadequate to Good
· Staff recruited safely with references and DBS checks completed
· Sufficient numbers of staff deployed; call times and lengths improved
· Staff received regular training, supervisions and support visits
· Safeguarding processes reviewed and concerns acted upon appropriately with referrals made
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candour; Working in partnership with othersNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
DCK Care Ltd was rated Inadequate and placed in special measures following a focused inspection that identified breaches across medicines, risk, staffing, recruitment, safeguarding and governance. Significant leadership shortfalls, lack of audits and unsafe care practices placed people at risk of avoidable harm.
Concerns (15)
criticalMedication management: “Medicines were not managed safely. Medicine records we reviewed did not contain the required information to ensure people received their prescribed medicines safely.”
criticalCare planning: “a person who lived with chronic obstructive pulmonary disease (COPD) did not have a care plan or risk assessment in place to detail how staff could safely care for them.”
criticalMissed or late visits: “They arrive late and rush in and rush out, which means they often don't wash my [relative] properly. When they are really late, my [relative] has often been in a wet pad for between 15 to 18 hours.”
criticalStaffing levels: “There were not enough suitably qualified staff to ensure people received care and support which resulted in early, late and missed calls. This placed people at risk of harm.”
criticalStaff training: “no staff had received a supervision in 2022 prior to our inspection and 39% of staff had not completed their training.”
criticalSupervision / appraisal: “no staff had received a supervision in 2022 prior to our inspection”
criticalSafeguarding: “Following a safeguarding incident investigated by the local authority not enough action had been taken to ensure the incident was not repeated.”
criticalIncident learning: “Lesson were not always learnt when things went wrong... No investigation had been completed internally by the registered manager”
criticalGovernance: “The provider did not utilise quality assurance systems. This meant they did not identify issues to drive service improvement.”
criticalLeadership: “there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalRecord keeping: “Staff files we reviewed did not evidence that all pre-employment checks were being carried out... none of the files we reviewed had two references”
moderatePerson-centred care: “The provider failed to ensure the culture was person centred, open or inclusive. This meant people were at risk of receiving poor care.”
moderateComplaints handling: “we found a number of questionnaires in care records, all of which had made concerns relating to call time, length of calls and in some staff performance. No action had been taken”
moderateInfection control: “two people we spoke with told us staff have not worn masks recently and they had to request staff put a mask on.”
moderateStaff competency: “Recently one staff member walked out on the call because they didn't like how my [relative] was, they have no understanding how dementia effects my [relative].”
Strengths
· The provider had an updated infection control policy to reflect the COVID-19 pandemic.
· The registered manager told us they had started completing spot checks to ensure all staff wore PPE.
· The registered manager told us they had taken action in order to address the late and missed calls by employing staff who could drive.
· People told us the registered manager was approachable.
Quality-Statement breakdown (9)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: How the provider understands and acts on the duty of candourInadequate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements