Interserve Healthcare Telford received an overall Good rating across all five key questions at its first CQC inspection in November 2016, with people and relatives reporting safe, caring and personalised support. Minor shortfalls were identified in MAR signature recording and the absence of trend monitoring for accidents and incidents, both acknowledged by the registered manager for remediation.
Concerns (3)
moderate
Medication management
: “we identified on one person's medicine records a number of missing signatures; signatures on a person's MAR would indicate people had received their medicine.”
minorIncident learning: “Although accidents and incidents were recorded, the system did not allow for trends to be monitored by the registered manager so that preventative action could be taken.”
minorStaffing levels: “one person told us there are occasions when there are insufficient staff to meet their needs.”
Strengths
· People and relatives consistently reported feeling safe and well supported by kind, considerate staff.
· Staff received tailored, individualised training including shadowing shifts for up to four weeks before working alone.
· Safe recruitment practices were in place, including DBS checks completed prior to staff starting work.
· People were involved in care planning and reviews, with monthly visits introduced to respond to changing needs.
· Staff respected people's privacy, dignity and preferences, with detailed, up-to-date individual care plans.
Quality-Statement breakdown (18)
safe: Safeguarding people from abuseGood
safe: Risk managementGood
safe: Staffing levelsGood
safe: Safe recruitmentGood
safe: Medicines managementGood
effective: Staff training and inductionGood
effective: Consent and Mental Capacity ActGood
effective: Nutrition and hydrationGood
effective: Healthcare professional involvementGood
caring: Kindness and compassion of staffGood
caring: Involvement in careGood
caring: Privacy and dignityGood
responsive: Person-centred care and individual preferencesGood
Interserve Healthcare - Shropshire & North Wales was rated Good across all five key questions at its July 2019 inspection, maintaining the rating achieved at its previous inspection in December 2016. The service demonstrated consistent, person-centred care delivery, safe medication and staffing practices, effective governance, and a culture of openness and continuous learning.
Strengths
· People felt safe with consistent staff and were provided with rotas so they always knew who would be visiting them.
· Staff were well trained and competent, with regular refresher training, induction programmes and shadowing of experienced colleagues.
· People were treated with compassion, kindness and respect; relatives and people using the service reported high satisfaction.
· Care planning was person-centred, with people fully involved in planning and review of their care.
· Effective governance including weekly review of accidents and incidents, a lessons learned programme, and regular audits.
Quality-Statement breakdown (25)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
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: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood