safe:Insufficient evidence to ratewell-led:Insufficient evidence to rate
This targeted inspection of SK Care Coventry Ltd found that the provider had met the requirements of the Warning Notice relating to Regulation 17 (Good governance) and was no longer in breach of Regulations 12 or 17, with improvements in risk management, medicines management, and oversight. The overall rating remains Requires Improvement from the previous comprehensive inspection, as targeted inspections do not reassess all areas of a key question.
Concerns (3)
moderateCare planning: “1 person's choking risk assessment instructed staff how to position the person's head...but did not inform staff what changes to look for.”
moderateMedication management: “recording omissions we found on 1 person's medicine record had not been identified by the management team.”
moderateGovernance: “further time was needed for audits and checks to be fully effective and embedded...audits of medicine administration records had not identified the omissions we found.”
Strengths
· Risk management had improved; risks associated with choking, falls and health conditions such as epilepsy were assessed and regularly reviewed.
· Medicines management had improved; staff were trained and competencies regularly checked.
· An electronic monitoring system was implemented to alert management if a medicine had not been recorded as given.
· Management oversight improved; the provider introduced monthly care record checks, weekly and monthly medicines audits, and staff recruitment record reviews.
· Staff spoke positively about management support and regular team meetings reinforcing policies and procedures.
Quality-Statement breakdown (3)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongInsufficient evidence to rate
safe: Using medicines safelyInsufficient evidence to rate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careInsufficient evidence to rate
SK Care Coventry Ltd received a 'Requires Improvement' rating following a focused inspection of Safe and Well-led, downgraded from 'Good' in 2018, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified. Key failures included inadequate risk assessments, unsafe medicines management, incomplete care records, and ineffective governance systems, though staff were found to be caring and responsive to people's needs.
Concerns (6)
criticalCare planning: “Known risks had not been assessed which put people at risk of receiving unsafe care. One person had epilepsy and another person was at risk of choking when they ate or drank.”
criticalMedication management: “Records had not been completed to show when and which prescribed medicines had been taken or declined...the provider could not demonstrate people were receiving their medicines safely.”
criticalRecord keeping: “Accurate and complete records in respect of each person were not maintained...staff did not always have the information they needed to provide safe, personalised care.”
criticalGovernance: “Medicines audits had not been completed and audits of people's care records had not identified the concerns we found. This put people at risk of receiving unsafe care.”
moderateStaff competency: “A gap in 1 staff member's employment history had not been explored and a second staff member's file did not contain a reference from their last employer.”
minorCommunication with families: “Some relatives had not been invited to provide feedback about the service and told us they felt communication with the management team needed to be improved.”
Strengths
· People received their care calls at the times they expected, for the length of time agreed and from staff they knew.
· Relatives were confident their family members were safe with staff, supported by reliable, regular carers.
· Staff completed training in safe medicines management and their competency to administer medicines had been assessed.
· Staff had received training to protect both adults and children from the risk of abuse.
· Staff felt supported and valued by the management team.
Quality-Statement breakdown (8)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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 empowering; Engaging and involving people using the serviceRequires improvement
SK Care Coventry Ltd achieved a Good rating across all five key questions at its first inspection following registration in September 2017. The service demonstrated strong person-centred, culturally responsive care with committed leadership, though minor gaps were noted in the detail of moving and handling assessments and the availability of formal capacity authorisation documents.
Concerns (2)
minorCare planning: “one person's assessment told staff the equipment to use was a 'banana board' but there were no instructions about how to use this”
minorConsent / capacity: “where relatives had formal agreements to make decisions on people's behalf a copy of the authorisation was not available”
Strengths
· People felt safe with staff and received care from consistent, familiar carers who arrived on time
· Robust recruitment procedures including DBS checks and reference checks before staff began work
· Staff completed Care Certificate induction and ongoing training including medication, moving and handling, and safeguarding
· Registered manager conducted weekly visits to all service users to monitor wellbeing and service quality
· Person-centred care plans written from the individual's perspective, regularly reviewed and updated
well-led: How the provider understands and acts on the duty of candour; Working in partnership with others