Spring Cottages Home Care Limited improved from Requires Improvement to Good following a focused inspection on 3–4 January 2024, with the previous breach of Regulation 17 (Good Governance) now resolved. Safe, effective and well-led domains were all rated Good, with improvements noted in medicines management, staff supervision, and governance systems.
Concerns (4)
moderateGovernance: “At our last inspection the provider had failed to ensure systems were robust enough or developed to demonstrate good governance. This was a breach of Regulation 17.”
minorRecord keeping: “Where 1 persons MAR had not been signed as administered, the daily records confirmed it had been given. The registered manager confirmed they would take action to ensure all staff understood the process.”
minorCare planning: “One person's risk assessment was brief, the director confirmed they had taken action to ensure this record had been reviewed and was more detailed.”
minorConsent / capacity: “Some staff required further guidance to ensure they understood how to protect people. The registered manager and director said they would take action to ensure all staff fully understood MCA requirements.”
Strengths
· Medicines managed safely with weekly MAR audits, staff training and competency checks in place.
· Staff recruited safely with relevant pre-employment checks completed.
· People and relatives were highly complimentary about the skills and caring nature of the staff team.
· New comprehensive electronic governance system introduced and being embedded with audit trails and regulatory guidance.
· Supervisions and spot checks on staff performance were completed and documented.
Spring Cottages Home Care Limited received an overall rating of Requires Improvement at its July 2023 inspection, with breaches of Regulation 17 cited for inadequate governance, record-keeping failures, and absence of medicines competency checks and management audits since January 2022. People and relatives were consistently positive about the quality of care, staff skills, and communication, with safe and responsive day-to-day practice underpinning the Good ratings across Effective, Caring, and Responsive domains.
Concerns (7)
criticalRecord keeping: “Accident records had no details of the action taken and did not confirm management had reviewed them.”
criticalGovernance: “Audits book was being completed. However, this had not been done since January 2022 and had no evidence of any audits, the findings or the actions taken.”
criticalIncident learning: “We saw an incident that required a statutory notification to be submitted. However, this had not been submitted to the Care Quality Commission when required.”
moderateMedication management: “There was no record of completed competency checks for medicines administration.”
moderateCare planning: “Care records for one person did not contain detailed information about the management of a medical condition.”
moderateSupervision / appraisal: “More spot checks on care delivery and supervisions were required. This would demonstrate staff had the skills to deliver care to people.”
minorStaff competency: “New staff told us they completed a detailed induction. However, records to confirm what had been covered had not been done.”
Strengths
· People told us they felt safe and staff had received safeguarding training; people confirmed carers arrived on time and stayed for the full visit duration.
· Staff were recruited safely with relevant checks undertaken and no agency staff were being used.
· People were very positive about the care received, describing it as 'well organised', 'meticulous' and 'over and above'.
· Care plans were developed electronically and accessible via an app to people, relatives and staff.
· People were supported with end-of-life and palliative care needs, with DNACPR records maintained in the electronic system.
Quality-Statement breakdown (23)
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
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 lawGood
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier lives
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Good
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversity; Supporting people to express their viewsGood
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: End of life care and supportGood
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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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 staffGood
well-led: Continuous learning and improving careGood