Care Organiser received an overall rating of Requires Improvement due to a repeated breach of Regulation 18, with a notification of an abuse allegation failing to be submitted to CQC, and audit systems not identifying key governance concerns. The Safe domain improved to Good, reflecting effective medicines management, safeguarding processes, PBS planning, and adequate staffing.
Concerns (4)
criticalGovernance: “One notification was not submitted to the CQC for an allegation of abuse at the Canterbury House supported living scheme.”
moderateIncident learning: “audits in place these had not identified or resolved the concerns we identified regarding notifications, gaps in staff employment histories and personal emergency evacuation plans.”
minor
Record keeping
: “risks relating to how individuals would be supported to evacuate in case of an emergency were not always fully recorded although they had been assessed.”
minorStaff competency: “The provider did not always explore gaps in people's employment records and the registered manager told us they would do so going forwards.”
Strengths
· People were supported in line with the Mental Capacity Act 2005, with capacity assessed and best interest decisions made in consultation with relatives.
· Positive behaviour support (PBS) plans were in place for all people, with a dedicated PBS team reviewing all incidents.
· Medicines management was safe, supported by electronic records enabling real-time oversight and audit.
· Sufficient staffing levels were maintained and people confirmed staff availability was good.
· Staff received training in infection control, PPE, food hygiene, safeguarding, and medicines administration with competency checks.
Care Organiser was rated Requires Improvement overall, with a repeat breach of good governance and a new breach for failing to notify CQC of significant incidents including allegations of abuse. While medicines, recruitment, infection control, caring and responsive domains had improved to Good, inaccurate duplicate care plans, weak oversight of financial transactions, and inconsistent leadership oversight kept Safe and Well-led at Requires Improvement.
Concerns (7)
criticalGovernance: “The provider's systems to monitor the care people received were insufficient. Although there was a wide range of audits in place these had not identified or resolved the concerns we identified”
criticalRecord keeping: “Staff did not always have access to accurate records about people because two set of care plans were in place for each person on the first day of our inspection.”
criticalSafeguarding: “The registered manager had not always sent us notifications in relation to significant events that had occurred in the service as required by law, such as any allegation of abuse”
criticalCare planning: “These paper care plans were sometimes inaccurate e.g. one stated a person required food to be prepared in a way which could cause them harm.”
moderateLeadership: “the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
moderateIncident learning: “A professional told us they were concerned incidents were not always reported externally when necessary. This meant incidents may not always have been reviewed”
moderateSafeguarding: “poor oversight of financial transactions meant people could be at increased risk of financial abuse.”
Strengths
· Medicines were managed safely with no errors found and staff received training and competency assessments
· Robust recruitment practices including criminal records, references, fitness to work and identification checks
· Sufficient staffing levels with consistent agency staff to fill vacancies
· Staff received regular supervision, appraisal and training including the Care Certificate
· Good infection control practices and PPE usage with COVID-19 risk assessments in place
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to live healthier lives, access healthcare services and support
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Not rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversity; Respecting and promoting people's privacy, dignity and independenceNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: End of life care and supportNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Continuous learning and improving care; Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Working in partnership with othersNot rated