AmberGreen Health & Social Care was downgraded from Good to Requires Improvement following a focused inspection that identified breaches of Regulation 12 (safe care and treatment) due to unsafe medicines management and Regulation 17 (good governance) due to ineffective auditing. Risk assessments, recruitment practices, IPC oversight and incident reporting also needed improvement, although staff were viewed positively and safeguarding awareness was strong.
Concerns (12)
criticalMedication management — “Medication administration records (MARs) were written by the service. However, the information recorded was not sufficient to ensure the possible risks with administration were mitigated.”
criticalMedication management — “people who needed to have their medicines administered directly through a Percutaneous Endoscopic Gastronomy (PEG), there were no robust clinical protocols in place”
criticalMedication management — “Care staff made us aware of two incidents relating to no medicines in the home for a period of up to three and five days respectively.”
criticalGovernance — “The provider had failed to establish systems and processes to assess and improve the quality and safety of the service provided.”
moderateCare planning — “documentation for somebody diagnosed with type 2 diabetes had a risk assessment in place. However, it did not provide any information relating to signs staff should look out for”
moderateRecord keeping — “MARs were not always being completed by staff following the administration of medicines”
moderateStaff training — “Staff we spoke with had very little understanding of PRN (as and when required medicines) protocols.”
moderateIncident learning — “incidents and accidents had not been formally recorded or notified to the appropriate organisation even though the provider had confirmed a system was in place.”
moderateInfection control — “we were not assured all staff were following this policy regarding COVID-19 testing for staff. Staff are required to self-test twice weekly; the provider was unable to provide evidence of this.”
moderateOther — “The provider had not ensured safe recruitment practices were being followed. We looked at two recruitment records. For one of the applicants, references had not been certified”
moderateMissed or late visits — “information that we received highlighted several missed and unassigned visits... there was no recorded analysis of this information. This meant there was a possibility people weren't receiving planned care calls.”
minorComplaints handling — “An analysis of the information gathered was produced and highlighted some concerns with staff accents and communication. This concern was due to be followed up at the next team meeting, however this did not take place.”
Strengths
· All staff had completed safeguarding training and had a good understanding of how to keep people safe
· Relatives reported staff always wore PPE and there was a regular team of carers
· Staff felt supported by management with an open-door policy
· Relatives felt listened to by the provider and registered manager
· People's privacy was respected and dignity maintained
Quality-Statement breakdown (11)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement