JWM Healthcare LTD was rated Good overall at its first inspection, with Safe rated Requires Improvement due to gaps in risk assessments, medication records and recruitment files. The registered manager responded promptly to feedback with an action plan and immediate improvements to records and quality assurance.
Concerns (5)
moderate
Care planning
: “risk management plans were not always in place where risks had been identified. For example, a risk management plan for the use of a catheter had not been developed”
moderateMedication management: “the strength of some medicines was incorrectly transcribed and none of the MAR sheets were signed by staff who transcribed the information.”
moderateRecord keeping: “People's care plans were not always up to date, and some risk assessments had not been completed. People's medicine records were not always accurate or fully complete.”
moderateGovernance: “Quality assurance tools had not always been effective at identifying shortfalls and ensuring improvements were made.”
moderateStaff competency: “one staff recruitment file did not have a reference from the staff member's last employer. Recruitment records did not show satisfactory evidence of conduct”
Strengths
· Consistent staff providing good continuity of care
· Effective use of PPE and infection control
· Person-centred care reflecting people's likes, dislikes and cultural needs
· Strong partnership working with social workers, GPs and district nurses
· Registered manager known to people and families, responsive to feedback
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Working in partnership with othersNot rated