Baxter Life Care Limited received a Requires Improvement rating for the second consecutive inspection, with a continued breach of Regulation 17 (Good Governance) due to inaccurate care records, unsafe medicines management, and ineffective audit systems. Strengths include safe recruitment, a positive staff culture, and good safeguarding and infection control practices.
Concerns (6)
criticalRecord keeping: “One care plan stated the person could transfer and use a wheelchair; this person was immobile. Another care plan did not include known risks around suicide ideation.”
criticalMedication management: “Medicines records were at times contradictory and confusing. Staff were not always recording the amount of medication, or the times medicines were administered.”
critical
Governance
: “Audits had not identified and resolved the shortfalls we had identified on inspection in relation to care records and medicines administration concerns.”
moderateCare planning: “Documentation did not include all the information to guide staff around how to provide safe care and treatment. Care records did not always reflect accurate information.”
moderateIncident learning: “Accident and incident records did not have enough information to look for themes and prevent the events from happening again in the future.”
minorMissed or late visits: “There were times when care staff were late to calls and people told us they do not always get notified.”
Strengths
· Safe recruitment systems in place with DBS checks completed prior to staff starting work.
· Staff had completed medicines training and had their competency assessed.
· Consistent feedback from people who felt safe with care staff.
· Positive staff culture; staff were happy in their roles.
· Staff trained in safeguarding awareness and infection prevention including PPE use.
Quality-Statement breakdown (8)
safe: Assessing risk, safety monitoring and management; Using medicines safely; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
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: Engaging and involving people using the service, the public and staff; Working in partnership with othersRequires improvement
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
Baxter Life Care Limited was rated Requires Improvement overall following a focused inspection of Safe and Well-Led, driven by concerns over inaccurate care records, inconsistent risk management, and ineffective governance systems constituting a breach of Regulation 17. The provider and newly appointed manager responded promptly during the inspection to begin remedying shortfalls, and no evidence of harm to people was found.
Concerns (6)
criticalGovernance: “Systems to assess, monitor and improve the quality of the service had not been operated effectively. We found there was no systematic approach to quality assurance.”
moderateRecord keeping: “staff were assisting one person with a continence product that was not planned for... care plan simply said staff should 'assist' the person with tasks, but did not include what assistance they required”
moderateIncident learning: “we also found incidents where there was no record of action having been taken at the time of the incident.”
moderateCare planning: “records for six people... were not always accurate, up to date and reflective of people's current circumstances.”
moderateStaffing levels: “last minute changes to rotas, not enough travel time between calls in different areas, staff being told to attend two-carer calls on their own”
minorMedication management: “One person was prescribed creams but these were not recorded on the medicines records; during the inspection this was corrected.”
Strengths
· Staff were recruited safely with DBS checks, references and a probationary period in place.
· Robust infection prevention and control procedures with adequate PPE supply throughout the COVID-19 pandemic.
· People felt safe; staff trained to identify and report abuse with clear escalation routes.
· Detailed guidance recorded for complex care tasks such as hoist use, wheelchair transfers and specific medicines administration.
· Provider and new manager responded promptly during inspection to address identified shortfalls.
Quality-Statement breakdown (11)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, 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