Reablement SkILs received a 'Requires Improvement' overall rating due to breaches of Regulation 17 relating to unsafe medicines management and ineffective governance and audit systems. People experienced positive, person-centred care and the provider responded promptly to inspection findings by commissioning a full audit and implementing corrective actions.
Concerns (6)
critical
Medication management
: “Medicines administration records (MARs) were handwritten and did not always provide clear information to staff about how to administer people's medicines.”
criticalMedication management: “Where people were prescribed regular doses of medication, the time of administration was not recorded. This meant we were not assured there was the prescribed gap between doses.”
criticalGovernance: “Robust systems were not in place to monitor, review and improve the quality and safety of the service. This placed people at risk of harm. This was a breach of regulation 17(1).”
moderateIncident learning: “Accidents and incidents were reported, and action taken to mitigate the risk of events occurring...the registered manager did not have a system to analyse and review themes and trends.”
moderateCare planning: “One person had fallen and there were no risk assessments in place.”
minorRecord keeping: “Care records could be improved to ensure they contained more individualised information about people's needs and goals.”
Strengths
· People and relatives spoke positively about person-centred care and felt safe and secure with staff.
· Safe and consistent staffing levels were in place with good feedback on punctuality and call times.
· Staff received safeguarding training and had a good understanding of how to recognise and report abuse.
· Effective infection control measures were in place and staff had access to personal protective equipment.
· Staff received induction, supervision, and training to carry out their roles effectively.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people, promoting a positive person-centred cultureGood
well-led: Working in partnership with others; Continuous learning and improving careGood