Following multiple breaches at the previous inspection, Individual Care Services demonstrated significant improvements across safeguarding, risk, medicines and governance, achieving an overall Good rating and exiting Special Measures. Effective remained Requires Improvement due to ineffective systems for tracking healthcare appointments, leading to missed hospital visits, and incomplete recording of best-interest decisions under the MCA.
Concerns (5)
moderate
Care planning
: “the system to identify important appointments for people to attend was not as effective as it should be, this meant important health appointments had been missed.”
moderateCommunication with families: “the registered manager only became aware a person had missed four hospital appointments when we informed them. This demonstrated improvement was still required to ensure effective communication”
moderatePerson-centred care: “One person was receiving treatment following a serious illness and had missed important hospital appointments which meant a risk to the person's recovery.”
minorConsent / capacity: “recording of decisions made in people's best interest were not clear and required more detail assessments would have benefited from further information about what support people had been given”
minorGovernance: “Significant improvements had been made since our last inspection visit, however systems still needed to become embedded in staff practice to become totally effective.”
Strengths
· Significant improvements made since last inspection; provider no longer in breach of regulations and removed from Special Measures
· Improved safeguarding systems with accessible reporting information and trained senior staff
· Risk assessments and support plans updated with sufficient information for staff to provide safe care
· New digital medication administration system introduced; staff retrained and competency assessed
· Strong infection control practices with PPE access and up-to-date guidance
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidance (MCA)Requires improvement
effective: Staff working with other agencies; supporting people to access healthcare servicesRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisionsGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships and follow interestsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about roles; understanding quality, risks and regulatory requirementsGood
well-led: Continuous learning and improving care; Working in partnership with othersGood
well-led: Engaging and involving people, the public and staff; promoting a positive cultureGood