ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2021-10-30

Framework: KLOE · 16 pages · 97 KB · PDF

Requires improvement

safe: Requires improvementeffective: Goodcaring: Goodresponsive: Requires improvementwell-led: Requires improvement

Welcome Support, a small domiciliary care agency in Tunbridge Wells, received an overall rating of Requires Improvement on its first inspection, with breaches of Regulation 17 (Good Governance) and Regulation 18 (Notifications) identified due to ineffective auditing, inconsistent care records, unaudited MAR sheets, and failure to submit statutory notifications. Staff were praised for their compassionate, person-centred approach and effectiveness in meeting people's needs, with Good ratings awarded for both Effective and Caring domains.

Concerns (9)

criticalGovernance: “The provider had failed to have effective governance systems in place to asses, monitor and improve the quality of the service that was provided to people.”
criticalSafeguarding: “The registered manager had raised a potential safeguarding concern with the local authority. However, a statutory notification had not been sent to the Care Quality Commission (CQC).”
criticalIncident learning: “Statutory notifications had not been submitted to CQC for an allegation of abuse and when there had been an expected death.”
moderateMedication management: “Protocols were not in place for people requiring 'as and when needed' medicines such as, pain relief. This left the person at risk of either receiving too much or not enough of their prescribed medicines.”
moderateMedication management: “Medication Administration Records (MAR) had not been completed consistently. Missing signatures were found on people's MAR which could not provide assurance.”
moderateCare planning: “Care plans contained an inconsistent level of detail and personalisation. Some records were very detailed and outlined how the person wanted their needs met and other records lacked detail.”
moderateRecord keeping: “Some people had comprehensive risk assessments and guidelines... Whereas other people's care records contained no information about risks posed to them and others.”
minorStaff training: “Full employment histories including an explanation of any gaps in employment had not been documented.”
minorEnd-of-life care: “Care records lacked detailed outlining the care and support the person wanted to receive at the end of their life.”

Strengths

· Relatives consistently praised staff and felt their loved ones were safe, with staff knowing people well and providing consistency of care.
· Staff promoted independence, dignity and privacy, and supported people to make their own choices.
· Thorough inductions with staff assessed as competent before delivering care independently.
· Staff worked effectively with external health professionals including SALT, occupational therapists and GPs.
· People's communication needs and equality characteristics were assessed and recorded, with accessible formats provided.

Quality-Statement breakdown (22)

safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced diet

Inspection reports (2)