The Angels on Call improved from Inadequate to Requires Improvement and exited Special Measures, but remained in continued breach of Regulation 12 due to unsafe medicines administration processes for one person. Governance, recruitment, infection control and safeguarding had improved, though the provider's audits had not identified the medicines issue and new processes needed time to embed.
Concerns (5)
criticalMedication management: “The processes in place around this practice were not robust and did not allow staff to effectively check the medicines they were administering.”
moderateMedication management: “Whilst we saw the medicines audits had been completed, the issue we have reported in our safe section had not been highlighted by the provider audits.”
moderate
Governance
: “improvements had been made, further improvement were required to ensure the service management and leadership was inconsistent.”
minorRecord keeping: “one record gave conflicting information on moving and handling techniques.”
minorStaff training: “the administrator was still completing training to support them in their role.”
Strengths
· Improved recruitment processes including DBS checks, no longer in breach of Regulation 19
· All staff administering medicines had received appropriate training
· Staff received safeguarding training and demonstrated awareness of responsibilities
· Improved infection prevention and control practices, including COVID-19 testing and vaccination compliance
· Improved processes to protect people from financial abuse with itemised receipts
Quality-Statement breakdown (10)
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongGood
well-led: Duty of candour and opennessGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive person-centred culture and engaging people and staffGood
well-led: Continuous learning and working in partnership with othersGood