safe:Insufficient evidence to ratewell-led:Insufficient evidence to rate
This targeted inspection of Ave Maria Care (Wolverhampton) found that the provider had successfully addressed Warning Notices relating to Regulations 12, 13, and 17, with improvements made to safeguarding, medicines management, care planning, and governance. The overall rating remains Requires Improvement as only the specific areas of concern were assessed; safe and well-led key questions were inspected but not re-rated.
Concerns (5)
criticalSafeguarding — “During the last inspection the system for reporting abuse was not clear for staff or managers.”
criticalMedication management — “At the last inspection time specific medicines were not always administered at the correct time.”
critical
Governance
— “At the last inspection some audits were not thorough or regularly undertaken and therefore ineffective.”
moderateCare planning — “During the last inspection we found care plans did not always contain information about people's health conditions.”
moderateStaff training — “During the last inspection staff were not always trained in peoples specific health conditions.”
Strengths
· Safeguarding reporting systems improved; staff now able to identify and report abuse appropriately.
· Medicines now administered safely with side effects documented in care plans and EMAR.
· Care plans updated to include specific guidance for health conditions and audited regularly.
· New governance and auditing systems introduced providing better oversight of the service.
· New administrator and senior carer roles introduced to support monitoring and oversight.
Quality-Statement breakdown (3)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and management, Using medicines safelyNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
Ave Maria Care (Wolverhampton) received an overall rating of Requires Improvement at this focused inspection, remaining in breach of Regulations 12, 13, and 17 with warning notices served for failures in safe medication management, safeguarding reporting, and ineffective governance systems. While staffing levels had improved and staff were described as caring, systemic failures in care planning, medicines oversight, incident learning, and audit effectiveness continued to place people at risk of harm.
Concerns (10)
criticalSafeguarding — “The registered manager had not always reported these to the local authority's safeguarding team. They had not always put measures in place to minimise risk of further abuse.”
criticalMedication management — “Staff were not aware of the side effects of people's prescribed medicines, and there was no information or guidance recorded in people's care plans about these.”
criticalMedication management — “I don't check this as it's on the box, so I follow that. This meant staff administered medication in an unsafe way and placed people at risk of harm.”
criticalGovernance — “The provider's governance systems were not effective and had not enabled them to continually assess, monitor and improve the quality and safety of the service.”
criticalCare planning — “People's care plans and risk assessment did not always provide staff with information on guidance on people's individual risks, such as those associated with epilepsy and Parkinson's disease.”
moderateIncident learning — “Lessons learnt were not always identified through the Trend analysis and Safeguarding audits or fed back to the staff team.”
moderateRecord keeping — “There was conflicting information in people's care plans, meaning staff may support people unsafely, depending on which part of the care plan they followed.”
moderateMissed or late visits — “People and relatives told us they were concerned about care call times being changed without them being made aware.”
moderateStaff competency — “Staff we spoke with were not always aware of people's individual risks or how to offer support to people in line with their specific needs.”
minorInfection control — “Some people told us not all staff wore PPE. One person told us, 'They are slipping a bit with masks'”
Strengths
· Staff suitability checks including DBS and employment references completed before starting employment
· People were happy with staff and found them to be caring; privacy and dignity maintained
· Registered manager investigated complaints openly and honestly and acted on concerns raised
· Provider worked in partnership with health and social care professionals with appropriate referrals to GPs and district nurses
· Staffing levels improved following recruitment; care call issues had reduced
Quality-Statement breakdown (10)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionRequires improvement
safe: Learning lessons when things go wrongRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
Engaging and involving people using the service, the public and staff; Continuous learning and improving care
Ave Maria Care (Wolverhampton) was rated Requires Improvement overall at its first inspection, with breaches of Regulations 12, 13, 17 and 18 identified in relation to unsafe medicines management, inadequate safeguarding processes, insufficient staffing, and failed governance and quality assurance systems. Caring and responsive practice by frontline staff was a relative strength, though leadership culture, risk oversight and consistency of service delivery fell significantly short of expected standards.
Concerns (11)
criticalMedication management — “one person required time sensitive medicine to treat an infection. The service did not plan visits from care staff, or record administration outcomes effectively to ensure the person received their medicine correctly.”
criticalMedication management — “A safeguarding enquiry substantiated concerns about a person being over medicated with diabetic medicine due to care call times being too close together. This caused the person to fall into a deep sleep.”
criticalStaffing levels — “one person experienced 73 changes to their scheduled call start times in one month and 14 care calls were either too early or late.”
criticalSafeguarding — “The provider received whistle-blowing information regarding potential risk of abuse, however failed to comprehensively investigate the concerns or inform the local authority safeguarding team.”
criticalGovernance — “The providers governance and quality assurance processes failed to provide effective oversight in identifying and monitoring risks for people. Auditing of care records was not thorough.”
moderateIncident learning — “Lessons were not learned following previous incidents regarding medicine management.”
moderateSupervision / appraisal — “Not all staff were provided with consistent supervision sessions... three of the 25 staff employed did not receive supervision within this timescale.”
moderateInfection control — “People and staff did not have individual COVID-19 risk assessments in place for use in reducing associated risk of transmission during care visits.”
moderateLeadership — “Staff described working within a negative and unsupportive environment. Several staff we spoke with said they were leaving the service or intended to do so due to increased work pressure.”
minorCultural competency — “the service's assessment documentation did not include sections to identify people's race or ethnic background, gender or sexual orientation.”
minorComplaints handling — “one relative told us 'We have made many complaints to the office, but they don't take any notice.'”
Strengths
· Staff treated people with respect, compassion and dignity; people felt well supported and cared for.
· Staff completed appropriate training and regular competency spot checks were carried out.
· Safe recruitment practices were followed including DBS checks, employment history and references.
· Care plans identified people's needs and staff knew people well, including communication needs and use of Flash cards.
· Staff supported people to maintain social relationships and activities, and were alert to changes in health needs.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
well-led:
Requires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Working in partnership with othersGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement