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

Inspection report · 2022-05-11

Framework: KLOE · 16 pages · 83 KB · PDF

Requires improvement

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

First inspection of this domiciliary care agency found breaches of Regulations 9, 12 and 17 due to inadequate risk mitigation plans, care plans not updated to reflect current needs, and ineffective governance systems. Staff were caring and well-trained with safe recruitment, but topical medicines recording, MCA practice and quality assurance required improvement.

Concerns (8)

criticalCare planning: “Risk assessments were not always robust enough to help reduce the risk of avoidable harm to people. Risks to people had not always been assessed and where risks were identified, a risk mitigation plan was not always completed.”
criticalCare planning: “Care plans not having up to date information meant there was a risk people might not receive appropriate care according to their needs and preferences. This was a breach of regulation 9 (Person centred care).”
criticalGovernance: “systems were either not in place or robust enough to demonstrate safety was effectively managed. This was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateMedication management: “Medicines were generally managed safely, but prescribed creams were not always correctly identified or recorded.”
moderateMedication management: “One of the medicines was time critical, but guidance around this was not included in the care plan, which meant the medicines may not have been given to the person at the right time to ensure it was effective.”
moderateConsent / capacity: “The principles of the Mental Capacity Act were not always followed. This meant people were not always supported to have maximum choice and control of their lives.”
moderateRecord keeping: “We found the health risk assessment for one person recorded they did not have a catheter when they did.”
moderatePerson-centred care: “The provider had care plans in place, but these were not always updated appropriately when people's needs changed. This meant care plans were not always personalised to service users' needs.”

Strengths

· Safe recruitment procedures were followed with appropriate checks on staff suitability and criminal checks
· Staff completed safeguarding training and the provider had safeguarding and whistleblowing procedures in place
· Staff received induction in line with the Care Certificate, annual training and supervision
· Staff followed appropriate infection prevention and control practices and were provided with PPE
· People and relatives reported staff were warm, kind, friendly and respectful of dignity and privacy

Quality-Statement breakdown (25)

safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law

Nika Care

Inspection reports (2)