Craegmoor Supporting You in the Midlands was rated Requires Improvement overall, with breaches of Regulation 17 (good governance) and Regulation 18 (staffing/training and supervision). While the service was caring and responsive with strong person-centred values, shortfalls in mandatory training, induction, supervision, recruitment checks and ineffective governance systems undermined safety and effectiveness.
Concerns (9)
critical
Staff training
: “we found shortfalls in training that had been deemed mandatory by the provider. This also included shortfalls in the provision of induction, safeguarding, medicines, and people handling.”
criticalSupervision / appraisal: “There were arrangements to provide staff with regular supervisions however this was not always provided in line with the provider's policy.”
criticalGovernance: “The provider had failed to maintain good governance. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations, 2014.”
moderateMedication management: “the training records showed a significant shortfall in the online training which the provider had deemed mandatory for the role including competence checks.”
moderateStaff competency: “people were not always assured they would receive their medicines as prescribed, by staff who have the right competences to administer them.”
moderateIncident learning: “we found the system for ensuring lessons were learnt from events was not consistent through the service. Debriefs or incident analysis had not been undertaken in the cases we reviewed.”
moderateLeadership: “The service was not consistently well-led and leadership arrangements did not ensure effective accountability and oversight.”
moderateRecord keeping: “evidence to show induction completed by staff was missing.”
minorOther: “we found in one file employment gaps had not been adequately explored for one staff member.”
Strengths
· People and relatives reported feeling safe and gave positive feedback about staff being kind, compassionate and respectful.
· Care plans were comprehensive, person-centred and reflected people's choices, wishes and protected characteristics.
· Staff went the extra mile, supporting people with bucket lists, fundraising and accessing the community.
· Strong consideration of equality and diversity, including sexuality, religion, culture and disability.
· Effective partnership working with GPs, mental health teams, social workers and commissioners.
Quality-Statement breakdown (20)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrong; Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
effective: Staff providing consistent, effective, timely care; Supporting people to live healthier lives, access healthcare services and supportNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlNot rated
responsive: End of life care and supportNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff are clear about their roles, and understand quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Planning and promoting person-centred, high-quality care and support with openness; duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated