Obasan Services Limited remained rated Requires Improvement following a focused inspection of Safe and Well-led, with a continued breach of Regulation 17 due to inadequate governance, out-of-date risk assessments, incomplete recruitment records, and failure to identify trends from incidents. Despite positive feedback about staff conduct and safe medicines management, the service has been rated Requires Improvement for three consecutive inspections and has not made sufficient progress against conditions attached to its registration.
Concerns (6)
criticalGovernance: “The provider had failed to have a system in place to monitor and have oversight over the quality and safety of the service.”
moderateRecord keeping: “Some moving and handling risk assessments were out of date and individual infection control risk assessments had not been reviewed.”
moderateCare planning: “Care plans were not audited to ensure they were consistent with the care delivered. We found one care plan had not been reviewed as agreed.”
moderateStaff competency: “One member of staff's file did not contain their full employment history as required. References had been received for staff however, it was not always clear who had supplied the reference.”
moderateIncident learning: “Accidents and incidents were recorded individually. However, they had not been reviewed to identify trends and enable learning through the service.”
minorInfection control: “Some people told us that staff did not always wear their face masks as required by the service.”
Strengths
· Medicines management was safe; staff were trained and competency spot checks carried out regularly; MAR checked and audited monthly.
· People felt safe and spoke positively about staff, describing them as kind, respectful and reliable.
· Staff had received safeguarding training and the registered manager had a good understanding of keeping people safe.
· Sufficient staffing levels in place; people told us staff visited at agreed times.
· Registered manager maintained up-to-date Coronavirus guidance and sourced adequate PPE including 'grab bags' for staff.
This focused inspection of Obasan Services Limited found the service to be Good in both Safe and Well-Led, representing improvement from Requires Improvement at the previous inspection. The provider had successfully remedied a prior breach of Regulation 17 by strengthening governance, auditing systems, and recruitment processes.
Strengths
· Consistent staffing team who knew people well and adapted to changing needs
· Strong safeguarding knowledge and training across all staff
· Robust risk assessments regularly reviewed to maintain independence safely
· Safe medicines management with monthly MAR chart audits and competency spot checks
· Improved governance and quality assurance systems with monthly audits
Obasan Services Limited was rated Inadequate overall following continued and unresolved breaches of Regulation 12 and Regulation 17, including unsafe medicines management, absent risk assessments, ineffective governance, and a failure to implement improvements identified at the previous inspection. The service was placed into Special Measures; caring interactions between staff and people remained a notable strength.
Concerns (10)
criticalMedication management: “Medicine Administration Records did not include sufficient information to ensure that people received their medicines as prescribed. For example, there were gaps in recording.”
criticalCare planning: “People did not have risk assessments which guided staff about how to keep them safe. For one person living with diabetes, there was no diabetes care plan or risk assessment available.”
criticalGovernance: “Audits were not effective, as action had not always been taken to address the shortfall identified. Omissions in daily records and medicine records had been highlighted but had not been addressed.”
criticalRecord keeping: “The registered manager was unable to provide recruitment information for two of the staff. This meant we were unable to determine whether appropriate checks had been carried out.”
criticalIncident learning: “Accidents and incidents were not always recorded or investigated. This meant that investigations did not always take place to ensure all remedial actions were taken.”
criticalConsent / capacity: “Documentation to support decision-making in line with the MCA was not in place. The registered manager's responses were not in line with the framework of the MCA.”
criticalLeadership: “The registered manager did not have a good understanding of their regulatory responsibility and legal requirements. There were two ongoing breaches of regulations identified at the previous inspection.”
moderateStaff training: “Staff did not receive training in topics which reflected the needs of the people they supported. Examples included catheter care, diabetes and pressure area care.”
moderateComplaints handling: “The complaint had not been formally recorded, investigated or responded to in line with the providers' complaints policy. The registered manager told us they had not received any complaints.”
moderateCultural competency: “Documentation did not reflect details about people's protected characteristics and the registered manager did not have a good understanding about how to ensure people did not receive discriminatory care.”
Strengths
· Staff treated people with kindness and compassion; people and relatives gave consistently positive feedback about caring interactions.
· People felt safe with staff visiting regularly and relatives reported no safety concerns with carers.
· Staff respected people's preferences including choice of male or female staff, visit times, and personal routines.
· People were encouraged to maintain independence and staff supported health professional-prescribed exercises.
· Staff ensured essential information accompanied people admitted to hospital, including care plans and MAR.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Learning lessons when things go wrongInadequate
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood