Felicity Care remained rated Requires Improvement at this focused inspection, with breaches identified under Regulation 19 (fit and proper persons employed) due to unsafe recruitment practices including unreliable references and late DBS checks, and Regulation 17 (good governance) due to absent audits and inadequate policies. Despite positive feedback on caring staff, medicines management and infection control, the registered manager had failed to address issues from the previous inspection.
Concerns (10)
criticalGovernance: “The registered provider did not have effective systems and processes in place to assess, monitor and improve the quality of the services provided.”
criticalGovernance: “The lack of management audits and checks meant that the issues we identified during this inspection had not been identified by the registered manager.”
criticalStaff competency: “The registered provider had failed to operate effective recruitment procedures to ensure that persons employed meet the conditions as specified in Schedule 3.”
criticalStaff competency: “Three staff recruitment files contained references from the same companies with similar handwriting which suggested that both references from different companies may have been written by the same person.”
criticalStaff competency: “For three staff recruitment files, the Disclosure and Barring Service (DBS) checks had been completed after the person had started to work for the service.”
moderateRecord keeping: “Employment records listed on staff members application forms and references provided did not match those as listed on their CV.”
moderateMedication management: “The medicines management policy did not reference current National Institute for Health and Care Excellence (NICE) guidance on the management of medicines in the community”
moderateStaff training: “One combined competency assessment had been completed for one staff member and the registered manager. We were unsure why the assessment was combined and how the registered manager had assessed their own competency.”
moderateLeadership: “none of the actions taken, linked to the issues we identified at the last inspection.”
minorComplaints handling: “the complaints policy did not provide any information on the timelines within which the provider would deal with complaints received.”
Strengths
· People received their medicines safely and as prescribed.
· Risks associated with people's health and care needs were assessed and recorded as part of the care planning process.
· Care staff were able to describe the different types of abuse, the signs they would look for to recognise abuse and the actions they would take to report their concerns.
· Systems were in place to prevent and control the spread of infection, with PPE supplies and weekly COVID-19 testing.
· Care staff spoke positively of the registered manager as supportive, approachable and available.
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersNot rated