ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2022-04-03

Framework: KLOE · 16 pages · 78 KB · PDF

Requires improvement

safe: Requires improvementeffective: Requires improvementcaring: Goodresponsive: Goodwell-led: Requires improvement

First inspection of a small Oxford domiciliary care service identified breaches of Regulation 12 (safe care and treatment) for unsafe medicines management and inadequate accident/incident systems, and Regulation 17 (good governance) for ineffective quality monitoring. Care was rated Good for caring and responsive, with kind, person-centred staff, but Safe, Effective and Well-led were Requires Improvement.

Concerns (11)

criticalMedication management: “Where people were prescribed 'as required' medicines there were no protocols in place guiding staff when to administer the medicines.”
criticalMedication management: “Where people were prescribed topical medicines there was no record of the medicines on medicine administration records (MAR).”
criticalStaff competency: “Staff were not always trained, and their competency assessed to ensure they could administer medicines safely.”
criticalIncident learning: “no incident or accident form had been completed and no investigation had been completed.”
criticalGovernance: “Systems for monitoring and improving the service were not effective as they had not identified the issues we found during the inspection.”
moderateLeadership: “The provider did not have a clear understanding of their regulatory responsibilities. This had resulted in a breach of the regulations.”
moderateConsent / capacity: “they were unaware of their responsibility to complete capacity assessments where there were indications a person may lack capacity to make a decision.”
moderateStaff training: “The provider's training matrix showed that staff had not completed training in dementia care.”
moderateSafeguarding: “staff were not always aware of the external agencies they could notify if needed.”
moderateRecord keeping: “MAR did not always include the details of individual medicines to ensure staff had the information required to administer medicines safely.”
minorEnd-of-life care: “The care plans we looked at did not contain information relating to end of life wishes.”

Strengths

· Staff were kind, compassionate and respected people's privacy, dignity and homes.
· People were involved in developing their care plans, including cultural and religious needs.
· Effective recruitment processes including work history checks and pre-employment checks.
· Provider was extremely supportive in helping people access health professionals and equipment such as a hospital bed.
· Staff completed infection control training and care records included infection risk guidance.

Quality-Statement breakdown (21)

safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced diet

Same Ways Care Limited

Inspection reports (2)