Pooleview Support Services was rated Requires Improvement overall, with breaches of Regulation 17 (good governance) due to weaknesses in medication recording, daily case notes, DBS check updates, learning disabilities training and infection control policy. Care was found to be effective, caring and responsive, with kind staff and good partnership working, and the provider responded immediately to concerns raised.
Concerns (7)
critical
Governance
: “Governance systems had not been established to monitor and mitigate some risks to people's safety and welfare. This placed people at risk of harm.”
moderateMedication management: “The provider was not recording the total numbers of tablets and counting them after supporting people to take their medicines.”
moderateRecord keeping: “People's daily activity was not recorded in daily case notes. This made it difficult to evidence how staff were following people's care plan's and risk assessments to keep them safe.”
moderateStaff training: “Two members of staff had not completed any specific training to support people with a learning disability as part of their induction.”
moderateSafeguarding: “Two members of staff had not had their DBS (Disclosure and Barring Service) checks updated since 2015.”
moderateLeadership: “The service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
minorInfection control: “The infection prevention control policy did not contain specific guidance for staff on COVID-19 transmission reduction procedures.”
Strengths
· People received kind and compassionate care from staff who used positive, respectful language
· Provider was very present and visible in the service, approachable and took a genuine interest in people, relatives and staff
· Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both)
· Care and support provided in a safe, clean, well equipped, well-furnished and well-maintained environment
· Staff supported people to make decisions following best practice in decision-making
Quality-Statement breakdown (25)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood