Kapital Care (UK) Limited was rated Requires Improvement overall at this August 2023 inspection, with breaches of Regulation 12 (medicines management) and Regulation 17 (good governance) identified. While staff were caring, people felt safe, and effective care planning was in place, significant failures in medicines recording, auditing, risk assessment personalisation, and complaints documentation undermined the safety and governance of the service.
Concerns (8)
criticalMedication management: “Medicines were not always managed safely. Medicines administration was not always recorded on Medicines Administration Records (MARs).”
criticalGovernance: “Management did not complete checks and audits in relation to the completion of MARs. The last time a MAR audit was completed was 5 January 2023.”
moderateRecord keeping: “They failed to record all complaints, outcomes and lessons learnt on a centralised system.”
moderateCare planning: “One person had epilepsy, but there was no personalised risk assessment detailing signs to look out for and what action to take in the event of a seizure.”
moderateStaff competency: “Staff were trained in the safe administration of medicines...However, staffs' medicines competency was not checked to assess their ongoing level of skill.”
moderateComplaints handling: “There was no centralised system for recording complaints and their outcomes...no record of lessons learnt following a complaint.”
minorSupervision / appraisal: “Supervision notes...were generic and lacked detail about what was discussed during these sessions. It was also not evident that supervision sessions were tailored to individual staff.”
minorStaff training: “We found that some staff required refresher training and raised this with the registered manager who acknowledged this and said that staff were in the process of completing this.”
Strengths
· People and relatives felt safe in the presence of care staff, with positive feedback about kindness and care quality.
· Electronic call monitoring system in place to monitor care worker timekeeping and punctuality in real time.
· Staff felt well supported by management and reported positive morale and good communication.
· Infection prevention and control measures including PPE supply and COVID-19 policies were in place.
· Assessments and care plans were personalised and included protected characteristics under the Equality Act 2010.
Quality-Statement breakdown (22)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
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: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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: Improving care quality in response to complaints or concernsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffRequires improvement