West Lancashire Branch Office (AFG) received a Good rating across all five key questions at its first CQC inspection in January 2023, demonstrating a person-centred, well-managed supported living service for 57 people with a learning disability and/or autism. Minor shortfalls in medicines records, risk management documentation, and covert medicine consent clarity were identified but promptly addressed by the registered manager with improvement plans submitted post-inspection.
Concerns (4)
moderateMedication management — “We noted some shortfalls in the medicines records, which included discrepancies between the medicines administration charts and the prescription labels and the application of creams.”
moderateConsent / capacity — “We noted there was a lack of clarity around the covert administration of one person's medicines.”
minorRecord keeping — “We noted information in some people's hospital passports was brief and lacked person centred details.”
minorCare planning — “Risk management strategies had not always been developed.”
Strengths
· People were supported in a kind, sensitive and respectful way and involved in discussions about their support.
· Sufficient numbers of staff were deployed with good consistency; people usually received care from the same team.
· Staff received training in safeguarding, infection control, equality and diversity, and specialist areas relevant to people's needs.
· Strong multi-agency working praised by professionals: 'a great example of different agencies working in a collaborative manner'.
· Effective quality monitoring systems including audits, improvement plans, and a 3-monthly review of safeguarding data.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to live healthier lives, access healthcare services and support; Staff working with other agenciesGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
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: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: Supporting people to develop and maintain relationships; support to follow interests and activitiesGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles; Continuous learning and improving careGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood