Windrush Care achieved an overall rating of Good across all five key questions at this June 2018 inspection, having improved from Requires Improvement in April 2017. The service demonstrated safe, person-centred care with strong leadership, effective quality assurance systems, and consistently positive feedback from people, relatives and health professionals.
Strengths
· People and relatives consistently reported feeling safe and well cared for by kind, respectful staff
· Robust recruitment process including DBS checks, reference checks and investigation of employment gaps
· Medicines managed safely with annual competency reviews for administering staff
· All staff received regular supervision, appraisals and appropriate training including the Care Certificate for new starters
· Person-centred care plans with clear guidance, regularly reviewed with involvement of people, relatives and health professionals
Windrush Care was rated Requires Improvement overall at its first inspection in March 2017, with a regulatory breach identified for failing to operate effective recruitment procedures in contravention of Regulation 19. While the service demonstrated genuine strengths in caring and responsive practice, including compassionate end-of-life support and personalised care, governance failures around staff supervision, competency assessment and medicines record-keeping undermined its overall safety and effectiveness.
Concerns (6)
criticalStaffing levels: “People were not protected by robust staff recruitment practices... not all the checks required had been completed.”
moderateRecord keeping: “A medicine administration record had not been put in place for the administration of cream.”
moderateSupervision / appraisal: “This had not been carried out however for new staff who had started in post since October 2016.”
moderateStaff competency: “The assessment of the competency of staff through observation of practice and individual meetings was inconsistent.”
moderateGovernance: “Quality assurance systems, although in place, had not identified the shortfalls around the recruitment of staff.”
minorStaff training: “The manager had trained as a trainer... Evidence of this qualification was not available to verify their accreditation.”
Strengths
· People had developed positive relationships with staff and were treated with kindness, respect and dignity
· People were supported at the end of their life with sensitivity and compassion
· Care records were individualised and promoted people's independence
· Staff had a good understanding of safeguarding and how to recognise and respond to abuse
· Effective out-of-hours emergency support was in place for staff and people using the service
Quality-Statement breakdown (17)
safe: Recruitment and selectionRequires improvement
safe: Medicines managementRequires improvement
safe: Safeguarding and risk managementGood
safe: Staffing levels and continuityGood
effective: Supervision and competency assessmentRequires improvement
This focused inspection of Windrush Care checked whether a prior breach of Regulation 19 (fit and proper persons employed) had been remedied following the March 2017 comprehensive inspection. The provider had implemented improved recruitment processes and met the legal requirement, though the 'safe' rating remained Requires Improvement pending evidence of consistent good practice over time.
Concerns (2)
criticalStaff competency: “people were put at risk because all of the information required for new staff had not been obtained prior to employment.”
moderateStaffing levels: “At the time of the inspection there was no registered manager in post. There had not been a registered manager since July 2016.”
Strengths
· Provider followed their action plan and met Regulation 19 requirements for recruitment checks on new staff.
· New application form introduced prompting full employment history with gaps explored and verified.
· New staff did not start work before a satisfactory DBS check had been received.
· Previous employers contacted to verify character and competency of new staff.
· Quality assurance systems reviewed to confirm all recruitment checks completed for new staff.
caring: Relationships, dignity and respectGood
caring: Involvement in care planningGood
caring: End of life careGood
responsive: Personalised care planningGood
responsive: Independence and social activitiesGood