Eden Brook Home Care Limited (New HQ) was rated Requires Improvement following a focused inspection in October 2022, with regulatory breaches identified in safe care and treatment (Reg 12), fit and proper persons employed (Reg 19), and good governance (Reg 17), resulting in two warning notices. Key failures included untrained staff administering medicines, unsafe recruitment practices, ineffective governance oversight, and poor communication with people and families.
Concerns (10)
criticalStaff training: “Not all staff had received adequate training in moving and handling, safeguarding, or medication administration, this placed people at risk of harm from improper or unsafe practices.”
criticalMedication management: “Staff supporting people with their medicines without adequate training placed people at risk of harm... staff told us they had been working and administering medicines without being trained.”
criticalStaff competency: “The provider told us all staff had been competency assessed as safe to administer medicines. However, when speaking with staff, many confirmed they had not been assessed for medicines, or spot checks.”
criticalSafeguarding: “Not all staff had received adequate training in safeguarding, including how to spot the signs of potential abuse. A staff member told us, 'I can't remember if I did safeguarding training.'”
criticalGovernance: “The nominated individual had not maintained oversight of the service and was unaware of the concerns we raised during the inspection.”
criticalLeadership: “The nominated individual did not demonstrate an understanding of the duty of candour. Concerns identified during the inspection were dismissed, with a culture of blaming former employees.”
moderateRecord keeping: “Staff told us they didn't always have access to the information, or the information available via their mobile devices was limited. 'The care plans need updating.'”
moderateMissed or late visits: “On the weekend they come very late. One time it was 1 o'clock, another time it was 11 o'clock to help me wash and dress. When my family came at the weekend I was still in my nightdress.”
moderateCommunication with families: “People and relatives stated they were not informed when people were running late... A person told us, 'There is no knowledge of timings or a rota. They refuse to tell you who is coming.'”
moderatePerson-centred care: “People told us they had not been asked for their views or feedback... 'I've never actually seen a care plan. I assume there must be one somewhere.'”
Strengths
· Care plans were detailed and included information about how to support people well and included risk assessments.
· Staff were described as approachable; a care manager was praised by people and staff for responsiveness.
· The service was working within the principles of the MCA with appropriate legal authorisations in place.
· Infection prevention and control practices were assured, including effective use of PPE.
· The service worked with a local hospice to provide end of life care and referred people to external professionals such as Speech and Language and Occupational Therapy.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; safeguardingRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service and continuous learningRequires improvement
Eden Brook Home Care improved from Requires Improvement to Good overall following a focused inspection on safe and well-led, having met the requirements of Warning Notices related to Regulation 12 and Regulation 17. The well-led domain remains Requires Improvement as new governance systems need to be embedded, sustained and monitored, and the service was without a registered manager at the time of inspection.
Concerns (5)
moderateGovernance: “whilst supervisions and training were taking place, records used for the oversight of these areas lacked structure or were too informal.”
moderateRecord keeping: “Some record keeping was unstructured and informal.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post. The nominated individual had previously stepped back from the day to day running of the service.”
moderateStaff training: “At the last inspection, records showed not all staff had received the mandatory training needed to guide staff on how to support people safely and assess potential risks.”
minorIncident learning: “We identified some records were not always structured or clear.”
Strengths
· Electronic system (Birdie) used to access care plans, raise concerns, and alert management to incidents, medication issues and skin integrity concerns in real time.
· Management team met twice weekly to review every person supported, focusing on alerts and monitoring actions taken.
· Provider had over-recruited to ensure sufficient and consistent staffing, including evenings, weekends and bank holidays.
· Safe recruitment checks carried out including DBS checks and employment history verification.
· Staff provided with PPE and demonstrated effective infection prevention and control practice.