Caremark (Sevenoaks & Tandridge) was rated Good overall at its first inspection in February 2023, with caring, effective, responsive and safe domains all meeting required standards. Well-led required improvement due to insufficiently robust audits failing to identify generic risk assessments and incomplete incident reporting by staff.
Concerns (5)
moderate
Care planning
: “They are generic and all the same. I don't tend to read as they are all the same. Makes me worry that someone will have a fall and in their risk assessment it wasn't picked up on.”
moderateIncident learning: “We were made aware of at least two incidents that although had been responded to well by staff the registered manager and provider had not been made aware.”
moderateGovernance: “Audits were not always picking up on the shortfalls on lack of personalised risk assessments and the completion of incident reports.”
minorRecord keeping: “Complaints responded to were not always being recorded centrally. The registered manager told us they would address this.”
minorCommunication with families: “Staff told us they would benefit from having face to face staff meetings which were not currently taking place.”
Strengths
· Sufficient staffing levels with travel time between calls and systems to monitor late or missed visits
· Staff demonstrated good safeguarding knowledge and safe recruitment practices were in place
· Thorough inductions with competency assessment before independent working; staff praised training quality
· People and relatives consistently described staff as kind, caring, dignified and respectful
· Care plans reflected individual backgrounds, preferences and communication needs
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infection; Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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 preferences; End of life care and supportGood
responsive: Meeting people's communication needsGood
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: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood