This focused KLOE inspection of Royal Mencap Society - North Suffolk and Coastal Domiciliary Care Agency found the service Requires Improvement overall, downgraded from Good, due to inadequate epilepsy risk management, insufficient staffing levels at one supported living site, and governance failures in identifying and acting on these risks. Strengths included safe medicines management, robust infection control, person-centred care planning, effective safeguarding practice, and positive staff culture.
Concerns (6)
criticalCare planning: “one person's risk assessment was due for a six monthly review but had been left for 11 months. Another person's protocol about their emergency epilepsy medicine was incomplete”
criticalStaffing levels: “despite two staff being needed to support one person with their mobility needs, there were parts of the day when only one staff member was on duty”
moderateGovernance: “The issues we raised about the management of people's epilepsy and the staffing of one of the supported living services had not been proactively explored by the registered manager.”
moderateRecord keeping: “Care plans did not instruct staff to check in this way. Risk assessments stated staff should check people each hour, but did not specify how.”
moderateIncident learning: “we questioned the lack of timeliness in carrying out a thorough review of all plans and all risks relating to epilepsy”
minorPerson-centred care: “decisions about how to carry out night checks to keep people safe whilst ensuring their privacy needed review”
Strengths
· Medicines were managed safely with appropriate staff training and competency checks by service managers.
· Robust infection control procedures were in place, including COVID-19 measures, PPE use and staff training.
· Staff were safely recruited with a comprehensive induction; new staff not rushed into responsibilities.
· Staff demonstrated good knowledge of safeguarding, including how to raise concerns internally and externally.
· Care plans were person-centred, written accessibly and involved people in their own care planning.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Learning lessons when things go wrongRequires improvement
well-led: Promoting a positive, person-centred, open and inclusive cultureGood