Ensure Care Ltd was rated Requires Improvement overall following a focused May 2023 inspection, with regulatory breaches identified under Regulation 12 (safe care and treatment) and Regulation 17 (good governance) due to unsafe medicines administration records, unmitigated care risks, and ineffective audit systems. Strengths included a positive staff culture, effective partnership working with healthcare professionals, and good training practices.
Concerns (12)
criticalMedication management: “One person was prescribed heart medicine to be given twice daily. A MAR chart showed this person was only administered this medicine once daily, over the course of a month.”
criticalMedication management: “MAR charts did not always include dosage or special instructions, to ensure staff had the information they needed to provide people with the right medicine at the right times.”
criticalCare planning: “One person was at high risk of skin breakdown and had wounds which were treated by district nurses. However, their care plan lacked guidance for staff on managing the risk.”
criticalCare planning: “There were no risk assessments for catheters, and care plans lacked clear instructions for staff on their responsibilities relating to catheters.”
criticalGovernance: “Audits and governance processes to maintain oversight of the safety and quality of care were not operating effectively. This put people at increased risk of not receiving safe, quality care.”
criticalGovernance: “Important events and incidents were not notified to CQC as per regulatory requirements. In response to our feedback, notifications were submitted.”
criticalStaff competency: “One relative said, 'One carer pulled out my relative's catheter and my relative ended up in hospital.'”
criticalSafeguarding: “When safeguarding concerns were raised, the registered manager took action to investigate those concerns and refer them to the local authority. However, CQC were not always notified.”
moderateRecord keeping: “Quality assurance checks were not always recorded or available to view during the inspection. The manager told us that medicine competency observations were carried out, but there were no records.”
moderateConsent / capacity: “Two people's care records included a statement of capacity confirming they lacked capacity, which the registered manager advised us was incorrect.”
moderateComplaints handling: “The provider had a complaints policy. However, records to demonstrate how complaints were responded to, as per the provider's policy, were not available.”
moderateMissed or late visits: “Some people told us their call times were suitable, other people said they were too early or late. People did not always know which care staff were coming.”
Strengths
· Staff recognised the importance of keeping people safe from the risk of abuse and avoidable harm and were trained in safeguarding.
· Staff were trained in infection prevention and control and provided with Personal Protective Equipment (PPE).
· People's needs were assessed before they started using the service and care plans included eating and drinking support.
· The provider worked in partnership with other healthcare professionals to meet people's needs and respond quickly to health changes.
· Staff spoke positively about their training and the provider worked with the local authority to access face-to-face and practical training.
Quality-Statement breakdown (15)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood