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

Inspection report · 2023-04-01

Framework: KLOE · 14 pages · 89 KB · PDF

Requires improvement

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

Enlightenment Care Services Ltd received an overall rating of Requires Improvement at this focused inspection, with breaches of Regulations 11, 12, and 17 identified, including a Warning Notice issued for poor governance. Persistent failures from the previous inspection remained unresolved, particularly around mental capacity assessments, incomplete care records, absence of incident reporting systems, and ineffective quality assurance processes.

Concerns (7)

criticalCare planning: “Most care plans and risk assessments were incomplete or not up to date. Staff did not have access to detailed and accurate care records about people's current care needs and risks.”
criticalConsent / capacity: “No meaningful mental capacity assessments had taken place which placed people at risk of having decisions made which were restrictive or not in their best interests.”
criticalIncident learning: “There was no effective system in place to support lessons being learned when things went wrong...The system to record and analyse incidents and accidents on the new system was not yet established.”
criticalGovernance: “Quality assurance audits and checks in some areas of the service were not sufficiently robust to identify issues and take prompt action to remedy.”
moderateMedication management: “We found some gaps in medicine administration charts (MAR) which were not explained. This was not always identified promptly to confirm the reason and take action to remedy.”
moderateStaff training: “Some areas of care were not covered in the training programme such as learning disabilities/autism, safeguarding children, oral care, person centred care or the mental capacity act.”
moderateRecord keeping: “Information about whether people had made a DNACPR decision was not easily accessible at the time of inspection.”

Strengths

· People and relatives confirmed people were cared for safely and staff were described as 'so nice'
· Staff usually arrived within the agreed window of time and stayed for the full duration of the call length
· Safe recruitment practices were followed with pre-employment checks carried out
· Staff received training in adult safeguarding and infection prevention and control
· Staff worked in partnership with health and social care professionals to maintain people's health

Quality-Statement breakdown (15)

safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law

Inspection report · 2022-08-12

Framework: KLOE · 15 pages · 91 KB · PDF

Requires improvement

safe: Requires improvementeffective: Requires improvementcaring: Goodresponsive: Goodwell-led: Requires improvement

Enlightenment Care Services Ltd was rated Requires Improvement overall, downgraded from Good due to a breach of Regulation 17 (Good governance) caused by inadequate risk assessments, inaccurate MAR and call-timing records linked to a malfunctioning electronic care system, and incomplete mental capacity assessments. Caring and Responsive remained Good with positive feedback on personalised care, staff kindness, and management support.

Concerns (6)

criticalGovernance: “Lack of oversight on risk assessment, MAR, call timings and capacity assessments.”
moderateMedication management: “medicine administration records were not always being kept accurately... some medicines were being displayed as either not given, or being given at incorrect times.”
moderateCare planning: “Risk assessments were not always completed to fully document the risks present in people's lives, and guide staff with safe care.”
moderateConsent / capacity: “Mental capacity assessments were not always in place and did not always contain sufficient detail.”
moderateRecord keeping: “Call timings were not always recorded accurately, due to the electronic system not working.”
minorStaff training: “training was required for some staff who were not aware of how to prepare particular foods, due to cultural differences in dietary preferences and cooking.”

Strengths

· Staff recruited using safe recruitment procedures including DBS checks
· Effective infection prevention and control practices with proper PPE use
· Sufficient induction and ongoing training for staff
· Personalised care plans reflecting people's likes, dislikes and preferences
· People felt well cared for by staff who knew them well

Quality-Statement breakdown (23)

safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood

Inspection reports (3)