ReadyCQC — A weekly field guide to CQC home-care regulation

Inspection report · 2022-03-09

Framework: KLOE · 17 pages · 97 KB · PDF

Inadequate

safe: Inadequateeffective: Requires improvementcaring: Requires improvementresponsive: Requires improvementwell-led: Inadequate

81 Wood Lane was rated Inadequate overall and placed in special measures, with breaches of Regulations 12, 17, 18 and 19 due to absent care plans, unsafe medication records, inadequate recruitment checks and ineffective governance. While people reported feeling safe and well-treated by individual staff, systemic failures in oversight, training and risk management placed people at risk of harm.

Concerns (12)

criticalCare planning — “The provider did not have clear care plans or risk assessments in place which detailed the support people required.”
criticalMedication management — “Medication Administration Records (MAR) should specify the details of when prescribed creams should be applied... We found prescribed creams were not detailed on people's MAR charts.”
criticalStaff training — “One staff member had not received any training, from the provider, at all.”
criticalStaff competency — “medication training had not taken place for all staff or that staff competency had not been monitored and assessed in line with their own policies.”
criticalGovernance — “Quality assurance systems were inadequate. Potential risk and areas of improvement were not identified.”
criticalLeadership — “There were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalRecord keeping — “Some records were not available when requested at the time of the inspection at the office. This was due to documents such as care plans and risk assessments not being in place.”
criticalOther — “Suitable references had not been obtained prior to care staff members commencing work... the provider had not received an up to date criminal records checks clearance, prior to care staff commencing employment.”
moderateSupervision / appraisal — “The provider was unable to provide us with staff supervisions or meeting minutes as they had not kept written evidence of the discussions which had taken place.”
moderateInfection control — “Records did not show that care staff members had received training in the correct use of Personal Protective Equipment (PPE)... Just one care staff member had received infection and prevention training.”
moderateConsent / capacity — “Staff had not received training in people's rights under the MCA and when to act in their best interests to ensure peoples safety and welfare is maintained.”
minorEnd-of-life care — “Care plans did not incorporate advanced decisions or end of life planning. Staff had not received training in EOL care.”

Strengths

· People said they felt safe and were very happy with the support received.
· Staff demonstrated a good understanding of how to safeguard people from abuse and were aware of the whistleblowing policy.
· Staff knew people well and people reported having a good rapport with them.
· People were treated in a dignified and respectful way and given choice around their call times.
· The provider engaged with other health professionals such as GPs and district nurses to support people's changing needs.

Quality-Statement breakdown (21)

safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Learning lessons when things go wrongNot rated
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 reports (2)