First inspection since re-registration found a service rated Requires Improvement overall, with weaknesses in governance, record-keeping, mental capacity documentation, staff supervision and competency checks driven partly by COVID-19 pressures. Safe, caring and responsive domains were rated Good, with positive feedback from relatives and person-centred support, though effective and well-led required improvement.
Concerns (12)
moderate
Record keeping
: “Record keeping was not up to date and audits to assess the quality and safety of the service as a whole were not as regular or sufficiently robust.”
moderateGovernance: “Severe staffing pressures in relation to staff recruitment, retention and sickness had resulted in reduced management time impacting temporarily on governance and oversight of services.”
moderateConsent / capacity: “we found a lack of recorded consent on people's care files and mental capacity assessments had not been completed for all aspects of the persons care and support”
moderateStaff training: “A number of staff told us they were supporting people with behaviours that challenge and they had not had training in this area.”
moderateStaff competency: “Competency checks help to ensure staff have the necessary skills, to carry out their roles. These were not up to date for all staff.”
moderateSupervision / appraisal: “spot checks were not happening and supervision of staff varied in quality and frequency across the different sites.”
moderateStaffing levels: “Recruitment and retention of staff remained a significant challenge for this provider... staff sickness and vacancy rates had impacted on the quality of the service provision.”
moderateInfection control: “There was insufficient oversight of staff practice in relation to their infection control practices.”
moderateCare planning: “we were unable to see evidence of how people were actively involved in planning and reviewing their needs... care and support plans did not record regular outcomes for people.”
minorEnd-of-life care: “Staff had not received end of life training and people's advance wishes were not always recorded.”
minorMedication management: “prior to this incident the provider had not considered risks associated with aspiration and medicines for those on a softer diet.”
minorCommunication with families: “Relatives told us Mencap had not asked them for regular input or feedback about the quality of the service provided.”
Strengths
· Staff and management pulled together during COVID-19 to ensure people's commissioned hours were provided
· Safeguarding systems and training in place; staff knew how to report concerns
· Medicines audited regularly with annual reviews and STOMP principles followed
· Person-centred care plans giving good overview of needs and preferences
· Staff treated people with compassion, dignity and respect; diverse workforce reflecting service users
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot 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
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: Continuous learning and improving care: Working in partnership with othersNot rated