Everready Health and Social Care Solutions received an overall rating of Requires Improvement at its first inspection, with a breach of Regulation 17 (Good Governance) identified due to absent monitoring systems for missed calls, medicines competency, needs assessments, and key legal documents. Caring was rated Good, reflecting kind, dignified, and person-centred practice from staff.
Concerns (8)
critical
Governance
— “Ineffective quality monitoring systems could place people at risk of harm, and this is a breach of regulation 17, Good governance, of the Health and Social Care Act 2008.”
criticalMissed or late visits — “There were no monitoring systems to ensure calls were not missed. Two people told us they had experienced a missed call. This placed people at risk of harm.”
criticalMedication management — “Medicines competency assessments were carried out by the registered manager. However, we found the registered manager lacked knowledge of some questions they had assessed staff members of being competent.”
criticalEnd-of-life care — “There was no end-of-life care plan in place for the person... resuscitation could take place against the person's wishes, due to official documentation not being accessible.”
moderateCare planning — “There were no monitoring processes to ensure prior to people accessing the service, they were subject to a needs assessment.”
moderateConsent / capacity — “The registered manager could not be assured these family members had a legal right to make decisions on behalf of the person.”
moderateCommunication with families — “The registered manager was unaware of the Accessible Information Standard and there were no systems in place, should anyone in the future require support with communication.”
minorCultural competency — “There was no emphasis focused on equality and diversity during the assessment and care planning and this meant people needs may not be met the way they wanted.”
Strengths
· People were protected from potential abuse because staff knew how to recognise abuse and how to safeguard them.
· Risk assessments promoted people's independence whilst ensuring their safety.
· Staff used effective infection prevention and control measures including PPE and hand hygiene.
· People received kind and compassionate care and were treated with dignity and respect.
· Staff were supported through regular supervision, induction, and training including the Care Certificate.
Quality-Statement breakdown (25)
safe: Staffing and recruitmentGood
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
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: Supporting people to live healthier lives, access healthcare services and supportGood
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: Meeting people's communication needsRequires improvement
responsive: End of life care and supportRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement
well-led: Continuous learning and improving careGood