Transform Supported Accommodation Limited was rated Good overall following a September 2022 KLOE inspection, with Safe rated Good and Well-led rated Requires Improvement. A breach of Regulation 17 (good governance) was identified due to incomplete records and failure to act on people's feedback, alongside a recommendation to improve infection prevention and control practices.
Concerns (7)
criticalGovernance: “Appropriate records were not always maintained, up to date and complete. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”
moderatePerson-centred care: “People's views were gathered, but these were not always analysed and used to improve on the quality of the service.”
moderate
Complaints handling
: “One person said, 'When we complain, they tell us 28 days for response, and we don't hear back again'. A complaint log we reviewed did not include detailed information.”
moderateInfection control: “People told us the cleanliness could be better and that they had greasy kitchen floors, bed bugs and mice in their home.”
moderateRecord keeping: “Accident and incident records did not always include enough detail to demonstrate the lessons learnt. Staff interview notes were not maintained to evidence the selection process.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post. The previous manager resigned from their post in January 2022.”
minorIncident learning: “Accident and incident records did not always include enough detail to demonstrate the lessons learnt. The manager told us that lessons were learnt... however, these actions were not always recorded.”
Strengths
· Staff focused on people's strengths and promoted independence, supporting people to pursue interests and achieve aspirations.
· Medicines were managed safely with appropriate MAR records, locked storage, temperature monitoring, and competency-assessed staff.
· People were protected from abuse; safeguarding policies were in place and staff were trained in their responsibilities.
· Risks were identified, assessed, and had management plans covering a wide range of individual and health risks.
· The service worked in partnership with health and social care professionals including GPs, social workers and local authorities.
Quality-Statement breakdown (11)
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careNot 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: How the provider understands and acts on the duty of candourNot rated
well-led: Working in partnership with othersNot rated