North West Community Services (GM) Limited was rated Good overall following an announced inspection in October 2016, with strong person-centred care, well-trained staff, and robust safeguarding and quality assurance systems. The Well-Led domain was rated Requires Improvement due to the registered manager's failure to submit legally required notifications to the CQC, and recommendations were made regarding consistent medicines administration practices.
Concerns (6)
criticalGovernance: “The registered manager had not sent the Commission notifications as they are legally obliged to.”
moderateMedication management: “staff did not always follow safe working practices within the administration and recording of medicines procedures...items had been scribbled out or overwritten which is not good practice.”
moderateMedication management: “the medicines cabinet lock was broken and staff were storing people's medicines in a filing cabinet.”
moderateMedication management: “one member of staff...took both people's medicines to them...there was a risk that people could get the wrong prescribed medicine by accident.”
minorRecord keeping: “some people had not been assessed for having window restrictors in place.”
minorCommunication with families: “54% of relatives felt that staff listened to what they had to say and that 62% felt they were involved in making choices over their family members support.”
Strengths
· People felt safe and expressed high satisfaction with staff, with comments such as 'I feel very safe' and 'The staff are all very good'.
· Staff were well-trained, including Care Certificate standards, manual handling, food hygiene, first aid and medication awareness, with many working towards or holding diploma qualifications.
· Robust safeguarding procedures were in place and staff demonstrated awareness of whistleblowing and reporting responsibilities.
· Person-centred care plans including 'This is me' documentation, easy read formats, and pictorial communication methods were used effectively.
· Complaints were handled promptly and used as learning opportunities; all complaints in 2015 and 2016 were resolved in a timely manner.
Quality-Statement breakdown (16)
safe: Medicines administration and storageRequires improvement
safe: Safeguarding proceduresGood
safe: Risk assessments and incident monitoringGood
safe: Staffing levels and recruitmentGood
effective: Staff training and developmentGood
effective: Supervision and appraisalGood
effective: Mental Capacity Act complianceGood
effective: Nutrition and healthcare accessGood
caring: Dignity, respect and person-centred supportGood
caring: Involvement of people and familiesGood
responsive: Care planning and reviewGood
responsive: Complaints handlingGood
responsive: Activities and community engagementGood
well-led: Regulatory notifications to CQCRequires improvement
well-led: Quality assurance and governance systemsGood
Mediline Supported Living Greater Manchester received an overall Good rating across all five key questions at its July 2019 inspection, demonstrating safe, person-centred support for approximately 131 people with learning disabilities. Notable improvements were recorded in well-led, which rose from Requires Improvement to Good, underpinned by strong governance, impartial quality audits and an open, transparent culture.
Strengths
· Robust safeguarding systems with easy-read information enabling people to raise concerns
· No agency staff used; flexible staffing with people involved in interview processes
· Staff completed Care Certificate on induction with regular supervision and appraisals
· Monthly MAR audits with errors addressed through further training or supervision
· Person-centred care plans co-produced with people, reviewed regularly and reflecting individual needs