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

Inspection report · 2022-10-20

Framework: KLOE · 18 pages · 104 KB · PDF

Requires improvement

safe: Requires improvementeffective: Requires improvementcaring: Goodresponsive: Goodwell-led: Inadequate

Forest Green Care Services Ltd improved from Inadequate to Requires Improvement overall, but remained in continuing breach of Regulations 12, 17, 18 and 19 due to risk assessments, medicines, recruitment, supervision/training and governance failings. The service was placed in special measures because well-led remained Inadequate, despite Caring and Responsive being rated Good.

Concerns (15)

criticalMedication management: “we found gaps in people's MAR's which had not been identified and followed up. This meant it was not clear if people had not received their prescribed medicines”
criticalCare planning: “some areas of risk had not been assessed and not all records were completed fully... There were still no risk assessments for people living with dementia.”
criticalGovernance: “There was a clear lack of management oversight at the service. We were still not assured that regulations were followed and understood fully.”
criticalGovernance: “There were no regular checks or audits completed by the manager of the service.”
criticalLeadership: “widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.”
criticalRecord keeping: “A lack of robust record keeping meant medicines were not always managed safely.”
criticalRecord keeping: “changing records retrospectively could increase the risk of medicine errors occurring as the manager would not be able to identify and actions errors with staff”
moderateMedication management: “'When required', or PRN protocols in people's care plans were not always available and did not always include enough information to ensure medicines could be given safely.”
moderateStaff training: “no practical training was in place for manual handling just training online. This could people at risk and was not in line with health and safety legislation.”
moderateSupervision / appraisal: “for two staff members we could see no supervision records... We did not receive any evidence that these had taken place.”
moderateIncident learning: “We could not be assured the service was learning lessons when accidents and incidents occurred. There were no records to support this or track any incidents.”
moderateStaff competency: “in two of the staff files there were gaps in employment history... In another staff file there were only character references and no recent employment reference”
minorComplaints handling: “the service was not keeping any formal records of complaints just emails on the computer which were difficult to track”
minorEnd-of-life care: “there was no training in place for staff to support staff if they did take on anyone with end of life care.”
minorConsent / capacity: “While consent forms were in place some records regarding medicines consent were missing.”

Strengths

· People and relatives reported feeling safe and praised staff kindness and compassion
· Staff demonstrated a good understanding of safeguarding and infection control with access to PPE
· People treated with dignity and respect; privacy and independence promoted
· Responsive, individualised care with strong relationships between staff and service users
· Sufficient staff deployed to meet people's needs and high staff morale

Quality-Statement breakdown (21)

safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot 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

Inspection report · 2022-03-22

Framework: KLOE · 20 pages · 108 KB · PDF

Inadequate

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

Forest Green Care Services Ltd was rated Inadequate overall and placed in special measures, with multiple regulatory breaches identified including unsafe recruitment, insufficient staffing, unsafe medicines management, lack of risk assessments and care plans, and absent governance oversight. Although staff were described as kind and caring, widespread failures in leadership, training, record keeping and quality assurance placed people at risk of harm.

Concerns (17)

criticalMedication management: “Medicines were not managed safely... some of the MAR records had missing signatures... one person was having medicines administered through a feeding tube without a MAR chart in place”
criticalStaffing levels: “The provider had failed to deploy sufficient numbers of staff in order to meet people's needs and keep them safe. This was a breach of Regulation 18”
criticalStaff training: “Staff had not received all of the training relevant to their role... not all staff had received training on manual handling... only the nominated individual and the human resources manager had received safeguarding training”
criticalCare planning: “We found five people without a basic care plan. This meant staff would not have appropriate guidance on how to support people safely”
criticalPerson-centred care: “Failure to ensure people receive person-centred care and treatment that meets all of their needs is a breach of Regulation 9”
criticalGovernance: “The nominated individual did not have systems in place to effectively assess, monitor and improve the quality and safety of the service provided. They did not carry out any audits”
criticalLeadership: “There was a lack of positive leadership and guidance in the service which had led to care that was not person-centred... The nominated individual had no oversight of the service”
criticalRecord keeping: “A lack of robust record keeping meant medicines were not always managed safely... records were not maintained in line with legislation and regulations”
criticalSafeguarding: “New staff had not received any safeguarding training as part of their induction... the service could not demonstrate how they had assured themselves staff understood safeguarding”
criticalOther: “The failure to have safe recruitment procedures was a breach of Regulation 19... DBS checks... only in place for two staff members”
moderateSupervision / appraisal: “We did not see any records that showed staff were provided with supervisions (one to one meetings) with their line manager”
moderateIncident learning: “we could not be assured at the time of inspection that lessons had always be learnt when things had gone wrong... we could not be assured that effective processes were in place to review and identify learning”
moderateMissed or late visits: “Carers arrive at various times. Very random visits... They have been three and a half hours late... There was one missed call”
moderateInfection control: “not all staff had received training on infection control and uniforms were not always worn”
moderateConsent / capacity: “Records showed that not all staff had received training on the MCA and we were unable to speak to staff about their understanding”
moderateCommunication with families: “The provider had not sought feedback from people or their families through the use of a quality assurance survey”
minorEnd-of-life care: “When we visited the service, nobody was receiving end of life care. However, staff had not received training on end of life care”

Strengths

· People were treated with kindness and compassion by staff
· Staff wore appropriate PPE (gloves, masks, aprons) to keep people safe
· People were supported to access healthcare services and staff liaised with external teams (e.g. dietetic team, ambulance services)
· People were supported at mealtimes to access food and drink of their choice
· A complaints policy and procedure was in place with clear timeframes

Quality-Statement breakdown (21)

safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot 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 experience

Kingfisher Home Care Ltd

Inspection reports (3)