ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2021-10-30

Framework: KLOE · 15 pages · 85 KB · PDF

Requires improvement

safe: Requires improvementeffective: Goodcaring: Goodresponsive: Goodwell-led: Requires improvement

Fessey House received an overall rating of Requires Improvement, driven primarily by a breach of Regulation 12 relating to unsafe medicines management, including failure to administer PRN pain medicines on four occasions, ineffective handling of medication errors, and unsafe storage of thickening agents. The service demonstrated genuine strengths in multidisciplinary working, caring staff relationships, responsive care planning, and effective health access, with safe, effective, caring, and responsive domains each rated Good except for safe and well-led.

Concerns (8)

criticalMedication management: “on four occasions in November 2017, as required (PRN) medicines prescribed to treat pain, were not administered to a person requiring them due to an absence of suitably trained staff”
criticalMedication management: “a member of staff had made five errors between October 2016 and November 2017, and had continued to administer medications with no additional training or competency assessments”
criticalMedication management: “Thickening agents were not stored securely...kept in an unlocked kitchen cupboard...people could access the thickening agent”
moderateMedication management: “the temperature in the medication room frequently exceeded the maximum temperature for safe medicines storage”
moderateRecord keeping: “daily records did not always include these details...one person's daily record contained the entry, 'Lower body care cream applied'. This person was prescribed three different topical medicines.”
moderateIncident learning: “information was not effectively collated to allow effective identification of trends. This could mean that causes of accidents would not be known and addressed to prevent further occurrences.”
moderateGovernance: “medicines audits contained a 'check competencies' section, which was always recorded as being 'complete'. However, staff who had made medicine errors had not always had their competencies reassessed.”
minorConsent / capacity: “Staff did not always complete written capacity assessments or document best interest decisions.”

Strengths

· Excellent multidisciplinary working with social workers, mental health team, occupational therapists, physiotherapists, district nurses and GPs
· Sufficient staffing levels with low staff turnover resulting in an experienced team who knew people well
· Safe recruitment practices including DBS checks and references
· People received timely access to healthcare services
· Care plans were complete, regularly reviewed and gave clear guidance to staff

Inspection reports (2)