Miss Leanne Porter's first CQC inspection rated the service Requires Improvement overall, with breaches in Regulation 17 due to ineffective quality assurance systems failing to identify gaps in risk assessments, care plan recording and medication administration records. Caring, effective and responsive practice was consistently Good, with staff demonstrating strong person-centred values, safe recruitment, and effective multi-agency working.
Concerns (5)
criticalGovernance: “Quality assurance systems were not fully effective at monitoring the service or identifying areas for improvement. This was a breach of regulation 17(1)”
moderateRecord keeping: “some people's bowel monitoring charts and skin integrity reviews were not consistently recorded.”
moderateMedication management: “some people's medicine administration records (MAR) were not consistently completed.”
moderateCare planning: “where people had known allergies recorded, their care records did not contain specific risk assessments to inform and guide staff.”
moderateGovernance: “The audit form in place did not identify where people's medicines were not clearly recorded on the MAR chart or where there was no specific guidance for staff.”
Strengths
· People felt safe with carers; safeguarding training completed by all staff as part of the Care Certificate induction.
· Safe recruitment practices including DBS checks; staff continuity praised by relatives.
· Effective infection prevention and control systems; staff had access to PPE and completed relevant training.
· Care plans reflected individual needs and choices; staff demonstrated strong knowledge of people's needs and risks.
· Provider worked proactively with external health professionals including GPs, district nurses, dieticians and SALT.
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
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: 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: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood