Aroma Care People Ltd was rated Requires Improvement overall at its November 2022 inspection, with breaches of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) identified, relating to unmitigated care risks, unsafe medicines administration, and ineffective audit systems. The service was rated Good for Effective, with staff well-trained and people's needs appropriately assessed, but this was the third consecutive Requires Improvement rating.
Concerns (6)
criticalMedication management: “staff had administered doses of paracetamol to 3 people too close together. 1 person's records confirmed that had happened on 30 occasions in the 4 weeks prior to our visit.”
critical
Care planning
: “4 people had urinary catheters, but their care records lacked the information staff needed to help them identify and manage associated risks.”
criticalRecord keeping: “Accurate and up to date records in respect of each service user were not maintained.”
criticalGovernance: “weekly medicine audits had not identified the issues we found which placed people at risk of receiving unsafe care.”
moderateMissed or late visits: “I do not always get the 30 minutes support I should. It's more like 10 minutes, but they (staff) do arrive more or less on time.”
moderateIncident learning: “Lessons had not been learned and opportunities to make improvements had been missed.”
Strengths
· Staff recruited safely with references and DBS checks completed
· People felt safe with staff and safeguarding procedures were effective
· Staff training was up to date including MCA, safeguarding and infection control
· People supported to access healthcare and staff worked in partnership with other agencies
· Mental capacity assessments completed and consent obtained before care provided
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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
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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood