Coldbrock Healthcare received a Requires Improvement rating following a focused inspection in November 2022, with continued regulatory breaches under Regulation 17 (Good Governance) and Regulation 19 (Fit and Proper Persons Employed). While some improvements had been made since the previous inspection, medication administration records remained incomplete, recruitment checks were insufficiently thorough, and governance systems were not yet embedded or effective enough to identify key safety concerns.
Concerns (7)
criticalGovernance: “quality assurance and monitoring systems were not fully embedded and were not fully effective at addressing the shortfalls we identified on inspection.”
criticalRecord keeping: “People's medicines records were not always accurate, complete and contemporaneous. While this placed people at risk of harm.”
criticalMedication management: “"As required" time sensitive medicines, such as pain relief, were not always administered with the required minimum time gap in between administration.”
criticalStaff competency: “Safe procedures were not followed when new staff were recruited to ensure they were safe to provide care to people.”
moderateGovernance: “provider's audits had not identified the concerns we found in relation to medicines and recruitment.”
moderateRecord keeping: “we have found several gaps in the recording of the daily notes for one person.”
minorCommunication with families: “Can't say I hear from the office and I haven't had any requests for feedback about the company or the care.”
Strengths
· Risk assessments had been reviewed and rewritten since last inspection, with detailed information on support required to keep people safe.
· Staff had completed safeguarding training and demonstrated understanding of how and when to raise concerns.
· People and relatives were positive about care staff, describing them as friendly, kind, polite and respectful.
· PPE was available and correctly used by staff, confirmed by people using the service.
· The registered manager took immediate action following inspection feedback on paracetamol administration risk.
Targeted inspection identified breaches of Regulations 12, 17 and 19 covering unassessed risks, missed/late visits, poor recruitment checks, weak medicines recording and inadequate governance, with a Warning Notice issued for good governance. The service was downgraded from Good to Requires Improvement in both Safe and Well-led.
Concerns (13)
criticalCare planning: “Risks to people had not always been assessed or planned to ensure they received care safely.”
criticalStaff training: “Staff were supporting people with testing their blood sugar levels but had not received training from a competent health care professional to ensure they could undertake this task safely”
criticalMissed or late visits: “the provider had not explored the impact of these missed care visits on people's safety to determine whether additional risk management plans needed to be put in place”
criticalInfection control: “Regular Covid-19 staff testing was not being completed in line with current government guidance. The provider was unaware of the regularity of staff testing.”
criticalGovernance: “A structured quality monitoring system was not in place and all shortfalls had not been identified prior to our visit.”
criticalStaff competency: “Safe procedures were not followed when new staff were recruited to ensure they were safe to provide care to people.”
moderateMedication management: “There were gaps in the recording of people's medicines or medicines were recorded as having been administered late.”
moderateSafeguarding: “The provider had not always scrutinised all late or missed care visits to ensure people remained safe... to ascertain if a safeguarding referral to the local authority is required.”
moderateComplaints handling: “Records of complaints received from people were not kept to show how the service had responded to people's complaints.”
moderateRecord keeping: “The provider did not ensure records were kept of all care people received.”
moderateCommunication with families: “The provider did not collect feedback from people who used the service and their relatives. This meant that people's views were not sought to evaluate and improve the service.”
moderateIncident learning: “the service did not have an improvement plan in place to evidence actions taken to improve the quality of the service.”
moderateLeadership: “it was evident that the staff relied heavily on the registered manager for day to day support. The registered manager talked to us about the time constraints and volume of work in their job role.”
Strengths
· People were supported by a consistent staffing team that knew them well
· Staff had completed safeguarding training and demonstrated good understanding of how and when to raise safeguarding concerns
· Supplies of PPE were available to all care staff and staff knew how to use it correctly and safely
· Environmental risks were assessed and lone-worker safety measures were in place
· Staff received medicine training and competency assessments
Quality-Statement breakdown (6)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrong; Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; duty of candour; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Engaging and involving people using the service, the public and staff; Working in partnership with othersRequires improvement