Real PCS Solihull was rated Requires Improvement overall, downgraded from Good, due to weaknesses in risk assessment, medicines management, staffing levels and governance oversight. Caring, effective and responsive domains remained Good with positive feedback on staff kindness, personalised care planning and partnership working.
Concerns (11)
critical
Care planning
: “people requiring continence care did not have specific risk assessments in place for staff to follow or to monitor people's skin integrity due to these needs”
criticalMedication management: “there were no "as required" protocol's in place or the details of prescribed medicine was no longer current”
criticalMedication management: “Medicine Administration Records (MARs) did not always evidence medicines were offered or the outcomes of administration recorded accurately”
criticalGovernance: “Auditing of care documentation did not always identify issues relating to recording of risk assessments and medicine administration”
moderateStaffing levels: “We found there was not always sufficient numbers of care staff in place to ensure care visits were completed as required”
moderateMissed or late visits: “One person told us their night time care calls were cancelled at short notice. The registered manager confirmed this was due to shortness in staff”
moderateStaff training: “where staff had received specialised training for people's needs, for example catheter care or swallowing difficulties; they felt the availability and quality of training could be improved upon”
moderateStaff competency: “there were clear differences in the level of knowledge and confidence of staff when carrying out this care”
moderateRecord keeping: “The service did not record service schedule dates for equipment used to support people's mobility; and therefore, could not be assured the equipment was safe to use”
moderateLeadership: “The provider did not always have effective strategies in place to manage shortfalls in staff numbers”
minorSafeguarding: “one member of staff did not have a new DBS check completed within a reasonable time period”
Strengths
· Staff understood people's needs and risks and knew how to raise concerns
· Safe recruitment processes including DBS, references and employment history checks
· Staff completed safeguarding training and understood their responsibilities
· Appropriate PPE provision and infection prevention training including Covid-19 precautions
· Care aligned to Care Certificate Standards with full induction before independent practice
Quality-Statement breakdown (24)
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: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to access healthcare servicesNot 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: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot 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: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated