Care Village Care, an extra care housing service in Nottingham, was rated Requires Improvement overall at its first inspection in November 2021, with breaches of Regulation 12 due to significant medication record inconsistencies and ineffective governance audits failing to identify safety risks. Strengths included kind and caring staff, robust safeguarding processes, effective infection control, and personalised, dignity-respecting care delivery.
Concerns (9)
criticalMedication management: “a person required a patch...every three days. Records showed the patch had been given every four days. This error had not been identified by the staff administering the medicine.”
criticalMedication management: “the guidance for the amount of paracetamol a person should have in one day was not recorded...given this medicine five times a day on several occasions.”
criticalGovernance: “the audits for the assessment of the risks related to medicines and ensuring care plans and risk assessments were always reflective of people's current needs were not effective.”
moderateMedication management: “Protocols for the administration of 'as needed' medicines were not always in place...could result in inconsistent medicine administration.”
moderateCare planning: “risk assessments that had been completed over a year ago with no evidence of a review date and other risk assessments that did not have the date of completion recorded.”
moderateCare planning: “one person had a catheter bag and the care plan stated how staff should empty the bag. However, there was no corresponding risk assessment on how to minimise the risks of cross infection.”
moderateLeadership: “Some people referred to a previous registered manager, others referred to the deputy manager. Few were aware who the current registered manager was.”
minorComplaints handling: “they rarely received feedback or a follow-up to their concern. One person told us that whilst their complaint had been listened to, they did not have confidence that it would be acted on.”
minorIncident learning: “it was not always clear what actions had been taken to reduce the risk of recurrence or whether the actions taken had been effective.”
Strengths
· People were protected from the risk of abuse and neglect; allegations were investigated and reported to relevant agencies appropriately.
· Sufficient numbers of trained and qualified staff were in place; recruitment checks were carried out prior to new staff commencing.
· Robust COVID-19 infection prevention and control policies and procedures were in place.
· Staff received five supervisions per year and an annual appraisal; training was completed across a wide range of required areas.
· People were supported to have maximum choice and control; staff acted in the least restrictive way in line with MCA principles.
Quality-Statement breakdown (25)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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 supportNot rated
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood