We assessed Alcedo Care South Lakes between 30 October 2024 and 26 November 2024. We looked at all 5 key questions; safe, effective, caring, responsive and well-led. The service provided personal care to people living in their own homes. When we last inspected Alcedo Care South Lakes we found a breach of the regulations relating to good governance. During this inspection we found the provider was no longer breaching the regulations. Staff told us they received very good support and they worked well as a team. There were good staff support systems and a staff recognition scheme to reward good practice. The provider had effective systems to identify and investigate allegations of abuse and identify lessons learnt. Staff understood their role in safeguarding. They had completed specific safeguarding training, as well as a range of other care-related training courses. New staff were recruited safely. Medicines were managed safely. Regular audits were completed so potential errors could be identified and addressed quickly. The provider’s mission, values and care philosophy were focused on delivering high quality and personalized care. There were effective quality assurance (QA) systems, which provided real time information to enable managers to act swiftly to address any issues. A newly developed dashboard provided a pictorial snapshot of performance and progress. Incidents, accidents, safeguarding allegations and medicines errors were regularly analysed to identify the root cause and recommend appropriate actions. There were good opportunities for staff to share feedback through regular meetings. The provider had systems to share any learning and other important information with staff. The provider had developed links with a range of external partners and had received external recognition for the care provided. There were clear strategic goals to develop the service and invest in staff retention and recruitment.
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Alcedo Care South Lakes received an overall rating of Requires Improvement at its first inspection, with Safe and Well-Led both rated Requires Improvement due to a breach of Regulation 17 arising from ineffective governance systems that failed to identify an out-of-date topical medicine in use, incomplete risk assessments for equipment, and missing statutory safeguarding notifications to CQC. Caring, Effective, and Responsive were all rated Good, supported by strong person-centred practice, positive feedback from people and relatives, and prompt remedial action taken by the registered manager during the inspection.
Concerns (5)
criticalMedication management: “a topical medicine was out of date and had continued to be used by care staff. The auditing systems over a 3-month period had not identified this.”
criticalGovernance: “provider had failed to make sure there were effective and robust systems in place to monitor risk and oversee the safe performance of the service. This was a breach of regulation 17”
criticalSafeguarding: “some statutory notifications that should have been submitted to us had not always been sent.”
moderateRecord keeping: “processes used for checking the quality of care plans did not identify that for 4 people risks associated with the use of some equipment such as bed rails and wheelchairs had not been completed.”
moderateCare planning: “care records did not provide a detailed plan for managing the risks associated with some of the equipment people required such as bed rails and wheelchairs.”
Strengths
· People consistently reported feeling safe and spoke positively about care staff, with one relative confirming no missed calls even during bad weather.
· Staff demonstrated person-centred values; people and relatives gave highly positive feedback about care quality and compassion.
· Effective recruitment checks were carried out to ensure staff suitability.
· Staff were trained across a wide range of areas including medicines management, infection control, equality and diversity, and MCA.
· Regular staff meetings facilitated learning from accidents and incidents, with lessons shared with the team.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
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: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving careGood
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
well-led: How the provider understands and acts on the duty of candourGood