First inspection of Bluedrive Care Homes found breaches of Regulations 9, 12 and 17 relating to person-centred care, safe care/medicines management and good governance, with risks to people not always assessed and ineffective quality monitoring including a malfunctioning electronic call monitoring system. Despite caring staff and positive feedback from people, the service was rated Requires Improvement overall.
Concerns (7)
criticalMedication management: “Medicines were not always safely managed... staff had only recorded the number of tablets they had administered to people on their MARs, they had not identified the types or doses”
criticalCare planning: “one person's care plan identified them as needing support from staff to manage their catheter, but this had not been risk assessed and their care plan didn't contain any guidance”
criticalPerson-centred care: “care plans did not always contain correct information about the support they needed, or identify any preferences they had in the way they wished to be supported”
criticalGovernance: “The provider's systems for monitoring the quality and safety of the service were not always effective in identifying issues or driving improvements.”
moderateRecord keeping: “the ECM system showed missed visits for one person during the week of our inspection but on further investigation, the system had not been updated with rota changes”
moderateStaff training: “the medicines management training they had completed had not instructed them to maintain complete and accurate records relating to people's medicines”
moderateStaff competency: “the registered manager was not familiar with the detail of the national guidelines for managing medicines in domiciliary care which led to shortfalls in staff practice”
Strengths
· Staff treated people with kindness, dignity and respect; people spoke positively about caring relationships with regular staff
· Sufficient staff deployed; people reported regular carers, no missed visits and consistent visit times
· Safe recruitment practices followed with appropriate pre-employment checks
· Staff completed safeguarding and infection control training and used PPE appropriately
· Complaints procedure in place and people were confident issues would be addressed
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to access healthcare servicesNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Managers and staff being clear about their roles; duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated