First inspection under new provider rated Requires Improvement overall, with a breach of Regulation 17 (Good Governance) due to ineffective quality assurance, medicines audits and incident oversight. Care plans were sometimes overdue and eMAR records inconsistent, though staff were caring, well-recruited and the registered manager had a clear improvement plan underway.
Concerns (9)
critical
Governance
: “Systems and processes in place to monitor the quality and safety of the service were ineffective. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance)”
criticalMedication management: “Staff did not always record when they had given people medicines on their electronic Medicine Administration Record (eMAR). For some of these instances other records conflicted the eMAR.”
moderateMedication management: “Protocols to guide staff how to administer medicines to people 'as required' were not always in place. Where they were, some staff told us they did not always know where to locate these.”
moderateIncident learning: “Opportunities to learn from incidents had been missed, as we could not identify how many accidents and incidents had occurred across the service or determine whether themes and trends had been identified”
moderateCare planning: “Some people's care plan reviews were overdue meaning care plans were not always reflective of their current needs.”
moderateRecord keeping: “Audits of care records did not identify where improvements were needed. We found care plans did not always detail peoples current care needs.”
moderateMissed or late visits: “The provider failed to establish systems to monitor care calls, which restricted their ability to identify risks and address shortfalls.”
minorSupervision / appraisal: “Some staff supervisions were overdue. However, staff we spoke with felt well supported in their role.”
minorEnd-of-life care: “Care plans did not reflect people's preferences and wishes should they reach the end of their life.”
Strengths
· Staff were safely recruited with DBS checks and references
· People reported feeling safe and described staff as kind and caring
· Improvements to scheduling introduced travel time, reducing rushed/late calls
· Staff knowledgeable about people's healthcare needs and took prompt action when people were unwell
· Staff had good understanding of Mental Capacity Act and supported people in least restrictive way
Quality-Statement breakdown (24)
safe: Using medicines safely; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
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: Staff working with other agencies; Supporting people to live healthier lives, access healthcare services and supportGood
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: End of life care and supportGood
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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving careRequires 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