Certain Care Ltd was found to have made enough improvement at this focused inspection to no longer be in breach of regulations 12, 13, 17 and 19, with new infection control, recruitment, safeguarding and governance systems in place. However, these systems needed time to embed, so both Safe and Well-led remained rated Requires Improvement.
Concerns (5)
moderateGovernance: “these new systems and processes developed by the provider were not fully in place and needed time to embed and be effective.”
moderateInfection control: “the provider had no formal systems in place to routinely test staff for COVID-19.”
moderateSafeguarding
: “people had been placed at risk of harm or abuse. The registered manager had not followed their own policies and procedures, acted on, or raised, potential incidents of abuse”
moderateStaff competency: “appropriate recruitment processes had not been followed. Staff had not routinely been recruited in line with safe practices.”
moderateLeadership: “service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
Strengths
· Improved infection control with routine weekly COVID-19 testing and good PPE supply
· Medicines managed safely with trained staff, risk assessments and MAR audits
· Safeguarding policies and training updated; incidents now reported to local authorities
· Electronic recruitment system implemented with proper pre-employment checks
· Engaged a care consultant to implement new quality monitoring systems and audits
Quality-Statement breakdown (8)
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
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
well-led: Managers and staff are clear about their roles, and understand quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Working in partnership with others; How the provider understands and acts on the duty of candourNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated