Zion Care Services Limited remains rated Requires Improvement across all five key questions, with continued regulatory breaches under Regulation 9 (person-centred care) and Regulation 17 (good governance), primarily driven by persistent late calls, language barriers between staff and people, and inadequate quality assurance systems. Whilst improvements have been made since the previous inspection—including full implementation of an electronic medicines system and regular staff supervision—these have not been sufficient to achieve compliance.
Concerns (10)
criticalPerson-centred care: “1 document still referred to a person as having a 'normal' background.”
criticalGovernance: “Systems had not been established to ensure the quality and safety of the service was assessed, monitored and improved effectively.”
moderateMissed or late visits: “Timings are poor, occasionally they call us to tell us they're running late.”
moderateCommunication with families: “[My relative] has trouble understanding the carers, there is a language barrier. It is a mutual not understanding.”
moderateInfection control: “One relative told us staff did not always use sterile water and clean equipment which was needed to meet their relative's needs.”
moderateCare planning: “People's diverse needs under the Equality Act 2010 were recorded on their assessments but failed to identify how staff should support them.”
moderateEnd-of-life care: “People did not have end of life support plans in place and there was no evidence that people's wishes and feelings at that stage of their life had been discussed.”
moderateRecord keeping: “Quality checks did not identify where assessment documentation was not always consistent with people's care plans.”
minorConsent / capacity: “The assessments were generic and did not record which decision the assessment was in relation to.”
minorCultural competency: “Assessment records did not always contain appropriate language to describe people's backgrounds.”
Strengths
· Electronic medicines administration system fully implemented; medicines now administered safely and MAR records accessible to staff via app.
· Risk assessments in place to guide staff on mitigating risk, including for people with complex clinical needs.
· Staff completed induction, Care Certificate, and broad training opportunities including regular competency checks.
· Regular staff supervision implemented since last inspection, described as useful by staff.
· Care plans reviewed and improved since last inspection; personalised and providing detailed guidance to staff.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and supportGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: End of life care and supportRequires improvement
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 empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
Zion Care Services Limited received a Requires Improvement rating across all five key questions in its first CQC inspection, with enforcement warning notices issued for breaches of regulations covering safe care and treatment (medication management) and good governance. Key failures included unsafe medicines administration, absent mental capacity assessments, undertrained staff, inconsistent care planning, and ineffective quality assurance systems.
Concerns (16)
criticalMedication management: “one person was administered the incorrect medicine which resulted in paramedics being called... one person had received a double dose of medicine which placed them at risk of harm.”
criticalSafeguarding: “staff who told us they had not received safeguarding training and did not always understand how to keep them safe. One staff member told us, 'I've not had safeguarding training'”
criticalConsent / capacity: “Mental capacity assessments were not completed when required... people were not always able to consent to care and treatment in line with the law.”
criticalGovernance: “Systems had not been established to ensure the quality and safety of the service was assessed, monitored and improved effectively. This placed people at risk of harm.”
criticalStaff training: “relatives told us staff did not always seem knowledgeable about the needs of people living with dementia... not all staff were up to date with their training.”
moderateSupervision / appraisal: “Staff supervisions were undertaken when there had been a concern raised... However, they were not always undertaken regularly to enable the registered manager to identify any potential training needs.”
moderateCare planning: “People's care plans were inconsistent and were not always reviewed regularly... care plan documentation was not always accurate.”
moderateMissed or late visits: “Call logs showed that staff were often late and relatives told us staff seemed rushed. One relative told us, 'I can't remember the last time the carers came at the proper time.'”
moderatePerson-centred care: “People were not always supported in a person-centred way that reflected their wishes and preferences. Relatives told us this was because staff did not always have time to do this.”
moderateRecord keeping: “Checks were not sufficient to ensure information had been transferred over from paper records to electronic records accurately. This meant there were inconsistencies in people's care plans.”
moderateIncident learning: “not all accidents and incidents were recorded which meant that this analysis was not always accurate... where call times were cut short, they were not always investigated.”
moderateComplaints handling: “Recording of complaints and concerns was not consistent. Some issues had not been formally recorded and investigated in line with the provider's complaints policy.”
moderateCommunication with families: “relatives told us they weren't always informed when care staff were late. One relative told us, 'I ring up to find out where the carers are... I never get a phone call to tell me.'”
moderateStaff competency: “staff did not always have sufficient English language skills or knowledge about specific health conditions they needed to meet people's needs safely.”
minorCultural competency: “Staff sometimes conversed with each other in a language that people did not understand which relatives found disrespectful.”
minorEnd-of-life care: “People's end of life wishes and preferences had not been considered in their care plans.”
Strengths
· Staff wore PPE in line with current guidance and an infection prevention and control policy was in place.
· Staff worked alongside specialist nurses to provide effective care to people with complex clinical needs.
· People and relatives told us staff were lovely and caring.
· Relatives told us the registered manager was supportive, approachable and communicated with them effectively.
· The provider engaged positively with commissioners and the local authority in a quality assurance process.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Requires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careRequires improvement