ACS Care Services is rated Good overall following a focused inspection of Safe and Well-led on 24–25 August 2023, an improvement from Requires Improvement in Safe at the previous inspection. The service demonstrates strong safeguarding, risk management and leadership, with minor gaps in medicines recording and staff team meetings already being addressed by the registered manager.
Concerns (3)
moderateRecord keeping: “there were some gaps in recording by staff on paper medicines administration charts (MAR). The registered manager had identified this issue already and explained the action they were taking”
minorGovernance: “Team meetings involving all staff did not take place regularly but the registered manager planned to reinstate these so staff had opportunities to receive information, share learning”
minorRecord keeping: “tightening the oversight of medicines recording and the daily notes written by staff to ensure these were consistently completed accurately and to a good standard”
Strengths
· Staff were reliable, arrived within agreed time windows, and people were usually supported by a small team of familiar carers
· Safe recruitment practices followed; staff trained in safeguarding, MCA, infection control and medicines administration with competency checks
· Effective oversight of accidents and incidents with lessons learned communicated to staff to reduce recurrence
· Registered manager was approachable, open and transparent, with strong positive feedback from people, relatives, staff and health professionals
· Provider participated in innovative local authority/NHS pilot projects, including medicines, end of life care and urgent support, receiving exceptional feedback from health professionals
Quality-Statement breakdown (11)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood
ACS Care Services Ltd requires improvement overall, with governance systems failing to resolve persistent dissatisfaction around inconsistent care staff and late visit timings despite audit processes being in place, and medication administration records not being maintained in line with Royal Pharmaceutical Society guidance. The service performs well in safeguarding, staff training, consent practices and the caring attitude of individual staff, with people reporting they feel safe and treated with dignity.
Concerns (6)
moderateMedication management: “the provider did not maintain a record of medicines administered to people using the service. We have made a recommendation about the recording of medicines.”
moderateMissed or late visits: “The same person doesn't always come and they don't come at the same time. This makes me anxious.”
moderatePerson-centred care: “They are supposed to be here for 30 minutes but they only stay for 12 minutes.”
moderateComplaints handling: “My [relative] raised concerns as they were coming later and later at lunchtimes which stopped me going out. It didn't make any difference.”
moderateGovernance: “these systems had not been effective in resolving issues about people's dissatisfaction about call times and consistency of care staff visits.”
moderateStaff training: “one staff member had not completed any mandatory training since 2102 and another since 2013.”
Strengths
· People felt safe and staff were knowledgeable about safeguarding risks and reporting procedures
· Effective recruitment practices were followed including DBS checks, references and health checks
· Consent obtained from people in line with the Mental Capacity Act 2005 before care was provided
· Staff received regular training including safeguarding, dementia care and moving and handling
· People were treated with kindness, dignity and respect by individual care staff
Quality-Statement breakdown (12)
safe: Medicines managementRequires improvement
safe: Safeguarding and protection from abuseGood
safe: Staffing levels and recruitmentGood
effective: Consent and Mental Capacity Act complianceGood
effective: Staff training and supervisionGood
effective: Nutrition and health needsGood
caring: Dignity, respect and person-centred approachGood
ACS Care Services Ltd was rated overall Good at its August 2017 inspection, having sustained improvements from a previous Requires Improvement rating, but remained Requires Improvement for Safe due to insufficient travel time between calls causing persistent lateness affecting 8 of 11 people spoken with. All other key questions were Good, with particular strengths in caring relationships, medication management improvement, and quality assurance systems.
Concerns (5)
moderateMissed or late visits: “one person told us that on one occasion their morning call was late by over an hour. This resulted in them having their medicines later than prescribed.”
moderateMissed or late visits: “Of the 11 people we spoke with, eight of them raised dissatisfaction with the timings of their calls.”
moderateRecord keeping: “previously there were a high number of gaps and omissions on the Medication Administration Records (MAR) when staff had failed to sign the record”
minorCommunication with families: “people were not always informed when staff were running late... 'The staff are not very reliable and they often turn up late. They don't let me know if they are going to be late.'”
minorCare planning: “Some areas of the care plans would benefit from further detail, for example, when describing peoples dietary likes, the care plans recorded 'various'.”
Strengths
· People felt safe with staff; safeguarding training was in place and whistleblowing policies were accessible to all staff.
· Robust recruitment procedures including DBS checks, employment history and references were consistently followed.
· Staff received regular supervision, spot checks and annual appraisals and described training as thorough and relevant.
· People were treated with kindness and compassion; staff built meaningful relationships and respected privacy and dignity.
· Quality assurance systems including satisfaction surveys, routine audits and action plans were used to drive continuous improvement.
Quality-Statement breakdown (18)
safe: Staffing and travel time allocationRequires improvement
safe: Safeguarding and protection from abuseGood
safe: Risk managementGood
safe: Safe recruitment practicesGood
safe: Medicines managementGood
effective: Staff training and inductionGood
effective: Supervision and appraisalGood
effective: Mental Capacity Act compliance and consentGood
ACS Care Services Ltd was rated Requires Improvement overall at its June 2016 inspection, with breaches of Regulation 17 due to inadequate governance systems, failure to notify CQC of safeguarding concerns, and inconsistent recruitment procedures. The service performed well in effective, caring, and responsive domains, with staff described as compassionate and well-trained, and care plans person-centred and regularly reviewed.
Concerns (8)
criticalSafeguarding: “although potential safeguarding concerns were sent to the local authority safeguarding team, the service had failed to notify the Care Quality Commission (CQC) of these.”
criticalGovernance: “systems were not in place to review key data including incidents and accidents to identify any learning and areas for service improvement.”
criticalIncident learning: “incidents and potential safeguarding concerns had not been reported to the Care Quality Commission. This meant that incidents of concern had not been reported so they could be responded to appropriately.”
moderateLeadership: “the registered manager only visited the service on average once every two weeks which meant there was no consistent management oversight at the service.”
moderateRecord keeping: “We looked at the MAR charts for five people using the service and saw there were some gaps and omissions... staff had failed to sign the chart to say they had administered.”
moderateStaff competency: “In four of the files we found gaps in staff employment history, one of which was over six years. We were also unable to find up to date photographs and proof of ID for three staff members.”
minorPerson-centred care: “51 people had not been included in this exercise and their views had not been sought.”
minorMissed or late visits: “staff sickness had an impact on the timings of people's calls.”
Strengths
· Staff were trained in safeguarding, knew how to recognise abuse, and were confident in reporting procedures.
· Sufficient staffing levels were maintained to meet people's care needs.
· Medicines were managed safely with risk assessments and MAR charts; errors identified and addressed promptly.
· Staff received induction, on-going training, supervision, and spot checks supporting competent care delivery.
· People's consent was sought in line with the Mental Capacity Act 2005.
Quality-Statement breakdown (21)
safe: Recruitment proceduresRequires improvement
safe: Safeguarding notifications to CQCRequires improvement
This focused follow-up inspection of ACS Care Services Ltd found that the provider had addressed a breach of Regulation 17 by strengthening quality assurance systems and resuming timely CQC notifications. The well-led rating remains Requires Improvement as a longer track record of consistent good practice is needed before a rating change can be considered.
Concerns (3)
criticalGovernance: “potential safeguarding concerns and incidents of concern were not sent to the Care Quality Commission (CQC)”
moderateIncident learning: “systems or processes were in place to assess, monitor and improve the quality and safety of the services provided and to mitigate the risks”
moderateLeadership: “the registered provider had not consistently gained and acted upon feedback from people for the purposes of continually evaluating and improving services”
Strengths
· Quality assurance systems had been strengthened with more robust processes and more regular checks.
· Incidents were recorded, monitored and investigated appropriately with action taken to reduce risk of recurrence.
· All required CQC notifications submitted in a timely manner since the last inspection.
· Regular audits conducted covering environment, health and safety, medication, care plans and staff files.
· Annual satisfaction surveys showed positive responses and feedback was used to drive improvement.
Quality-Statement breakdown (1)
well-led: Quality assurance and governance systemsRequires improvement
responsive: Consistency of care staff and visit timingsRequires improvement