Transparent Care Limited deteriorated from Good to Requires Improvement overall, with concerns about safeguarding reporting, medicines, risk assessments, agency staff skills and quality monitoring lapses during COVID-19. The registered manager took prompt action on issues identified and caring and responsive remained Good, with a clear improvement plan underway.
Concerns (14)
critical
Safeguarding
— “We found occurrences where the service had not identified or reported potential safeguarding concerns to the local safeguarding authority as required.”
criticalMedication management — “Written protocols for when needed medicines were not always in place, controlled drugs records were not fully completed at one setting and stock control records did not balance for one medicine at another setting.”
criticalStaffing levels — “At one setting the service had not considered staffing levels at night to safely evacuate people in the event of an emergency.”
moderateGovernance — “Quality and safety audits had not been kept-up during COVID-19.”
moderateStaff competency — “We received feedback that some agency staff were not appropriately skilled or demonstrate the right values to meet people's needs and keep them safe.”
moderateCare planning — “Risk assessments were not consistently documented in response to people's needs. For example, one person's risk of pressure ulcers was not recorded.”
moderateRecord keeping — “Management and people's care records were sometimes incomplete or lacked enough written information about their support needs and risk.”
moderateIncident learning — “Incident reports were not always fully completed to confirm the manager had reviewed the incident or acted to mitigate risk.”
moderateConsent / capacity — “documentation about one person's mental capacity to consent contradicted information within their deprivation of liberty order.”
moderateLeadership — “We received mixed positive and negative feedback from people, their relatives and staff about the management of the service.”
minorStaff training — “Training in physical interventions and diabetes awareness had lapsed for some staff”
minorInfection control — “at a third setting cleaning products were not locked away at all.”
minorEnd-of-life care — “People's care plans did not include end of life preferences.”
minorCultural competency — “protected characteristics such as gender identify and sexuality were not captured.”
Strengths
· Staff demonstrated commitment, compassion and used positive, respectful language with people
· Staff had skills to interpret individual communication including Makaton, body language, sounds and symbols
· People supported to make choices, maintain independence and have control over their lives
· Complaints were logged, investigated and outcomes documented
· Registered manager was reflective, open and demonstrated a clear drive to improve the service
Quality-Statement breakdown (25)
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot 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 eat and drink enough to maintain a balanced dietNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationshipsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and 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: Duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated