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

Inspection report · 2022-07-15

Framework: KLOE · 18 pages · 102 KB · PDF

Requires improvement

safe: Requires improvementeffective: Goodcaring: Requires improvementresponsive: Requires improvementwell-led: Requires improvement

Concept Care Solutions Ltd (Edgware) was rated Requires Improvement overall, with breaches identified in safeguarding, good governance and staffing under the HSCA Regulations 2014, plus failure to notify CQC of significant incidents. Although effective care, medicines management and recruitment were rated Good, poor oversight, late/inconsistent visits, weak complaints handling and ineffective audits drove deterioration from the previous Good rating.

Concerns (12)

criticalSafeguarding: “People were exposed to the risk of harm because the systems in place to safeguard people from harm and abuse were not followed properly by staff.”
criticalGovernance: “Systems were not robust enough to demonstrate quality and safety was effectively managed.”
criticalStaffing levels: “The provider failed to ensure sufficient staff were employed to meet people's needs.”
criticalLeadership: “The registered manager who was also the provider, did not provide effective oversight and governance of the service's safety and quality to ensure all regulatory requirements were met.”
moderateMissed or late visits: “They are not always on time. They are sometimes an hour late...the agency stated they were short staffed and couldn't get anyone.”
moderateCommunication with families: “people were not always informed of who was scheduled to attend their care calls and were not informed when carers were running late.”
moderateComplaints handling: “others told us they had raised complaints with the service but not received a response.”
moderateIncident learning: “Although accident and incidents were recorded, these were not easily accessible during the inspection. It was clear the system in place to manage accident and incidents were not effective.”
moderateRecord keeping: “We found up to date records were not kept regarding improvements made to the service.”
moderatePerson-centred care: “Due to poorly coordinated visits and shortage of staff, people did not always receive support at their preferred times, their routine was disrupted because staff were late”
moderateStaff competency: “We feel safe with the regular carers, but not the stand ins, they don't seem to know what they're doing and I have to tell them what to do”
minorOther: “The registered manager and staff we spoke with were not fully aware of the legal requirement to follow the Accessible Information Standard.”

Strengths

· Safe recruitment practices with pre-employment checks completed before staff started providing care
· Medicines were administered safely with no gaps or errors observed in MAR records and competency checks completed
· Staff received infection control training and were provided with PPE
· Comprehensive and personalised needs assessments considering religious observances and gender preferences
· Staff completed the Care Certificate and received ongoing training and supervision

Quality-Statement breakdown (24)

safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
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

Inspection reports (2)