Town and Country Care Services Limited remained in breach of Regulation 17 due to persistent failures in medicines administration recording, with three overlapping systems creating confusion and gaps in records despite prior recommendations. Significant improvements were made in staff training, recruitment, risk management and partnership working, resulting in the Effective domain being upgraded to Good.
Concerns (3)
criticalMedication management: “In total there were three possible systems in place for staff to use to record the administration of medicines. This was potentially confusing and made it difficult to establish what medicines people had received and when.”
critical
Record keeping
: “The provider had failed to maintain accurate, complete and contemporaneous records in respect of each service user in relation to medication.”
moderateGovernance: “Managers completed audits of the service, including medicines audits...However, the processes introduced to rectify the issue had not been effective.”
Strengths
· Risks to people's health and well-being were identified and recorded with clear staff guidance on mitigation.
· Recruitment processes improved; pre-employment checks completed and application forms updated.
· Staff training improved, including specialist training such as catheter care, with protected time provided.
· Staff received regular supervisions mixing face-to-face meetings and observations of practice.
· Positive person-centred culture with managers described as open, available and respectful.
Quality-Statement breakdown (15)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
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
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 empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood
First inspection of this domiciliary care service identified breaches of regulations 17, 18 and 19 relating to governance, staff training and recruitment, with care plans/risk assessments missing for some health conditions and significant gaps in mandatory training. Despite these shortfalls, staff were rated caring and responsive, with a strong community ethos and positive feedback from people, relatives and external professionals.
Concerns (11)
criticalCare planning: “Some people were at risk associated with their specific health condition. There were no care plans or risk assessments in place to guide staff on how to support people in this area.”
criticalCare planning: “one person had an oxygen supply in their home which can be a fire hazard. There was no associated care plan or risk assessment in place.”
criticalStaff training: “out of 16 staff only four had completed food hygiene training, five had completed dementia training and four had completed training for personal care.”
criticalStaff training: “only two members of staff had completed training in either of these subjects [end of life care and the Mental Capacity Act].”
criticalGovernance: “Audits and checks of the service were carried out. However, these had failed to identify, or address, the shortcomings found at inspection.”
criticalStaff competency: “Recruitment systems to help ensure staff were suitable to work in the care sector were not robust. The application form did not require applicants to give an employment history or provide explanations for any gaps in employment.”
criticalStaff competency: “One member of staff, who had been working at the service since July 2022, only had one reference on their staff file; this was from a past employer where the applicant had worked in 1999.”
moderateRecord keeping: “We looked at one person's MARs in both formats and found there were several discrepancies between the two.”
moderateMedication management: “Due to IT issues the electronic MARs were not always completed to indicate people had received their medicine... it was not possible to evidence clearly when people had been supported with their medicine.”
moderateMissed or late visits: “There had been a recent event when a visit was missed. This had occurred after the visit had been reallocated due to staff sickness and the staff member newly assigned to the visit had not picked up the message.”
minorPerson-centred care: “People's paper care records did not contain details about people's preferred routines and the support they required at each visit.”
Strengths
· Caring and unhurried staff approach; people supported by staff they knew well
· Strong community-based ethos with active support for community involvement (e.g. weekly chip supper run, farm visits)
· Good safeguarding systems; concerns appropriately raised and staff understood signs of abuse
· Sufficient staff to cover all planned visits; managers covered visits when needed
· Strong team working culture; staff felt well supported by managers
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated