Five Star Homecare Leeds Ltd achieved a Good rating across all five key questions at its July 2023 inspection, representing significant improvement from its previous Requires Improvement/Inadequate ratings and resolving all prior regulatory breaches. Minor gaps in medication record-keeping and quality assurance processes were noted but did not constitute breaches of regulation.
Concerns (2)
minor
Medication management
: “medication audits had not identified that codes were not always being recorded by staff”
minorGovernance: “we also found examples when these had not been fully effective in identifying areas for improvement”
Strengths
· People and relatives were positive about staff and reported the service was safe with a positive impact on their lives
· Medication was managed safely overall, with trained staff and regular competency checks and medicine audits
· Robust risk management systems in place with detailed care plans and control measures
· Safeguarding improvements sustained; staff trained to identify and report abuse appropriately
· Safe recruitment practices including full employment history, references and DBS checks
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
Five Star Homecare Leeds Ltd's first CQC inspection found widespread governance failures, with breaches of four regulations covering safeguarding, safe care and treatment, consent, and good governance, resulting in an Inadequate well-led rating and overall Requires Improvement. Despite positive feedback from people and relatives about staff kindness and consistent care delivery, the provider failed to identify or act on significant risks around medication management, mental capacity, care planning detail, and quality assurance.
Concerns (10)
criticalMedication management: “We found several gaps in medication administration records (MARS); these had not previously been identified by the provider. We could not be sure if these were recording issues or if people's medication had been missed.”
criticalSafeguarding: “There had been occasions when safeguarding concerns had not been appropriately reported by the provider. This was a breach of regulation 13.”
criticalConsent / capacity: “We found some people who lacked capacity in relation to their care, had their liberty restricted as part of their care arrangements. This had not been previously identified by the provider.”
criticalGovernance: “The provider had failed to ensure the quality assurance processes in place were effective. Audits had either not been completed or those completed had not identified issues found at this inspection.”
criticalLeadership: “The provider's knowledge and understanding of regulations, best practice guidance or its own policies and procedures was limited.”
moderateCare planning: “People's care plans lacked detail in relation to important areas of their care, their preferences and how staff should support them.”
moderateRecord keeping: “Records were not always accurate, complete or contemporaneous. We found several concerns around the quality and accuracy of the records.”
moderateSupervision / appraisal: “Supervisions were not always happening in line with the provider's policy or being documented.”
moderateStaff competency: “The system in place to check competency of staff in this area was not robust. Medication audits were not being completed by the provider.”
minorPerson-centred care: “People's protected characteristics under the Equality Act (2010), such as religion and disability were not documented as part of the assessment process.”
Strengths
· People and relatives gave consistently positive feedback about staff being kind, caring and respectful.
· Overall recruitment was managed safely.
· Good infection control and prevention practices were in place, including effective COVID-19 pandemic management with appropriate PPE use.
· Care was delivered by a consistent team with no reports of missed or late visits.
· The registered manager was receptive to the inspection process and willing to learn and improve.
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experience
Requires 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
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning; Duty of candourInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement