Surecare Enfield was rated Requires Improvement overall following its October 2018 inspection, with a regulatory breach under Regulation 19 due to seven staff found working without legal permission to do so and insufficient oversight of recruitment documentation. The service demonstrated clear improvements since its 2017 inspection in risk assessment, staff training and medicines management, with Good ratings across Effective, Caring and Responsive domains.
Concerns (6)
criticalStaffing levels: “one staff member working did not have permission to live or work in the UK... a further six staff working for the service who did not have permission to work in the UK being identified.”
criticalGovernance: “the management team did not have sufficient oversight of ensuring documentation legally required for all staff was in place, such as references and up to date visa documentation.”
moderateRecord keeping: “management team were unable to confirm to the inspection team, prior to and during the inspection, an accurate number of people receiving personal care.”
minorRecord keeping: “staff should record full names when completing notes of care visits... where two staff attended a care call, only one staff member signed the visit for both care staff.”
minorCare planning: “We found one instance of a care plan not having been updated following a reduction in a person's package of care.”
minorPerson-centred care: “One person told us that they had requested a male carer which had not always happened. We saw that people's gender preferences were not documented in people's care assessments.”
Strengths
· Medicines were managed safely with no gaps or errors in MAR records and competency assessments completed.
· Staff received regular documented supervisions and an annual appraisal and felt supported.
· People and relatives praised the patient, caring and competent nature of care staff.
· Risks associated with people's care had been assessed with detailed guidance provided to staff.
· Staff received training in specialist complex care areas including stoma care, suctioning, assisted feeding and oxygen.
Quality-Statement breakdown (19)
safe: Fit and proper persons employed (Regulation 19)Requires improvement
safe: Risk assessments and guidance for staffGood
safe: Medicines managementGood
safe: Safeguarding systemsGood
safe: Staffing deployment and visit timelinessGood
effective: Staff training and competencyGood
effective: Mental Capacity Act complianceGood
effective: Supervision and appraisalGood
effective: Nutrition and hydration supportGood
caring: Dignity, respect and person-centred careGood
caring: Involvement in care planningGood
caring: Support for independenceGood
responsive: Care planning and documentationGood
responsive: Complaints handlingGood
responsive: End of life careGood
well-led: Oversight of staff recruitment and monitoringRequires improvement
well-led: Accuracy of people receiving care dataRequires improvement
well-led: Quality assurance and improvement planningGood
well-led: Staff and service user feedback processesGood
Surecare Enfield improved from 'Requires Improvement' to 'Good' across all five key questions, having successfully addressed previous breaches of Regulation 19 relating to staff recruitment. The service demonstrated strong person-centred care, effective governance through a new electronic monitoring system, and a well-supported staff team under new leadership.
Strengths
· Staff were kind, compassionate and caring, promoting people's dignity, privacy and independence
· Safe recruitment processes improved since last inspection, including Home Office visa status verification and DBS checks
· New electronic care management system introduced for real-time monitoring of call times and medicines administration
· Detailed, person-centred care plans reviewed regularly and reflecting people's daily routines and preferences
· Effective training programme including induction, shadowing, competency assessments, supervision and appraisals
Quality-Statement breakdown (23)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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
Surecare Enfield received an overall rating of Requires Improvement following inspections in August 2017, with three regulatory breaches identified relating to risk assessment (Regulation 12), governance (Regulation 17), and staffing/training (Regulation 18), most critically around untrained staff performing complex PEG feeding and suctioning tasks without management knowledge. The service performed well in caring and responsiveness, with positive feedback from people and relatives, improved medicines management, and robust safeguarding and recruitment practices since the previous inspection.
Concerns (7)
criticalStaff training: “Training records confirmed that training in PEG care was last provided in July 2015...training had not been provided and the lead carer...was instructing care staff in the care tasks.”
criticalGovernance: “Managerial oversight of a particularly complex care package was lacking as the registered and deputy manager were unaware that care staff were carrying out complex care tasks.”
criticalRecord keeping: “The person's care and risk assessment did not reflect the person's current care package and detailed guidance was not provided to care staff to support the person's PEG feeding regime.”
criticalStaff competency: “Staff had not received training to carry out PEG care and the lead carer was training other care staff in these tasks.”
moderateCare planning: “One person's manual handling risk assessment last completed in February 2016 stated they were unable to walk and used a wheelchair. However the person's care assessment completed in February 2017 referred to the person using a walking aid.”
moderateConsent / capacity: “We found instances of consent forms signed by relatives where their legal authority to do so was not documented.”
minorPerson-centred care: “In all care records reviewed the information contained in the section ['Things I would like to achieve'] was the same...This was not person centred and required amendment.”
Strengths
· Medicines were now safely managed with regular audits, completed MAR records, and regular competency assessments of staff.
· All staff had received safeguarding training and demonstrated understanding of types of abuse and reporting procedures.
· Staff received regular documented supervisions, one-to-ones, and annual appraisals.
· Safe recruitment practices were followed including DBS checks and right-to-work verification.
· People and relatives provided consistently positive feedback about the caring, kind, and respectful nature of care staff.
Quality-Statement breakdown (17)
safe: Risk assessmentsRequires improvement
safe: Medicines managementGood
safe: SafeguardingGood
safe: Staffing levels and missed callsGood
safe: Safe recruitmentGood
effective: Staff training and competencyRequires improvement
SureCare Enfield received an overall rating of Requires Improvement following a July 2016 inspection, with breaches of Regulations 11 and 12 identified relating to unsafe medicines management, inadequate individual risk assessments, and failure to operate within Mental Capacity Act principles. Caring, responsiveness and leadership were rated Good, with the recently appointed registered manager demonstrating proactive improvements, though these had not yet been fully embedded at the time of inspection.
Concerns (8)
criticalMedication management: “staff member administering the medicine recorded that they had supported the person to take seven tablets every morning, however the medicines list...stated that the person took six tablets every morning”
criticalCare planning: “person's risk assessment and care plan which had been completed in September 2015 had not been reviewed or updated to address the person's pressure sore”
criticalConsent / capacity: “consent forms were signed by relatives. Care files did not contain details as to why the person receiving care had not signed their care plan”
moderateStaff training: “17 members of staff had not received any mandatory training since 2012, 2013, 2014 and early 2015”
moderateRecord keeping: “concerns or errors noted were not logged or analysed for trends”
moderateIncident learning: “Accidents and incidents were recorded, however actions, outcomes and learning from accidents and incidents was not always identified”
moderateSafeguarding: “registered manager had not informed the CQC of two safeguarding referrals made to the local authority”
minorGovernance: “Complaints were not analysed for trends to identify if improvements could be made in particular areas”
Strengths
· People and relatives felt safe and spoke positively about caring, consistent staff
· Sufficient staffing levels maintained with robust recruitment procedures including DBS checks
· Comprehensive staff induction including shadowing experienced colleagues before solo working
· Regular supervisions on a quarterly basis and annual appraisals with development plans
· Person-centred care plans regularly reviewed and matched between home and office copies
Quality-Statement breakdown (15)
safe: Risk assessmentRequires improvement
safe: Medicines managementRequires improvement
safe: Staffing levels and recruitmentGood
safe: SafeguardingGood
effective: Staff training and inductionRequires improvement
effective: Consent and Mental Capacity ActRequires improvement
effective: Supervision and appraisalGood
effective: Health and nutritional supportGood
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with othersGood
effective: Access to healthcare
Good
caring: Caring and compassionate staffGood
caring: Dignity and respectGood
caring: Promoting independenceGood
responsive: Care planning and person-centred careGood
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement