The service exited Special Measures with Safe and Effective improving to Good after previous breaches of regulations 11, 12, 13, 17 and 18 were addressed. However, Well-led remained Requires improvement as recent governance improvements, including a new quality monitoring audit, needed more time to embed and demonstrate consistent good practice.
Concerns (4)
moderateGovernance: “At the time of this inspection, the first audit was underway but not yet complete.”
moderateGovernance: “we could not improve the rating for Well-led on this occasion because to do so requires consistent good practice over time.”
minorMedication management: “Staff had experienced some occasional problems with the new system, but these were decreasing.”
minorStaffing levels: “it had been difficult recruiting new staff, particularly during the peak of the COVID-19 pandemic. This had meant existing staff needing to cover sickness and leave between themselves.”
Strengths
· Staff described as kind, compassionate and personalised; one person said carers were 'Just brilliant.'
· Significant improvement in identifying and mitigating individual risks via new electronic records system
· Improved staff training including safeguarding, MCA, infection control and medicines administration
· Strengthened recruitment processes and required checks completed for new staff
· Improved understanding and application of the Mental Capacity Act with no unauthorised restrictions found
Quality-Statement breakdown (14)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies and supporting people to access healthcareGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staff; promoting a positive person-centred cultureRequires improvement
well-led: Working in partnership with othersRequires improvement
PACA, a domiciliary care agency providing 24-hour personal care to three people, was rated Requires Improvement overall and Inadequate for Safe, with breaches of Regulations 11, 12, 13, 17 and 18 placing the service into special measures. Inspectors found unsafe medicines management, unsafe recruitment, unassessed mental capacity, punitive staff practices toward people with learning disabilities and a serious lack of provider oversight.
Concerns (14)
criticalSafeguarding: “People were at risk of abuse from staff. Other staff failed to report poor practice witnessed by other staff towards people”
criticalMedication management: “Medicines were not safely managed. National Institute for Clinical Excellence (NICE) guidance was not followed in relation to medicines.”
criticalConsent / capacity: “Mental capacity assessments were not completed for specific decisions. Court of protection orders were not applied for people subject to continuous supervision and restrictions.”
criticalStaff training: “Staff were not attending training that ensure they had the skills needed to deliver personal care to people.”
criticalStaff competency: “The perception of some staff was that people with learning disabilities were to be treated as children and imposed punitive measures for some behaviours.”
criticalGovernance: “The provider lacked leadership and operational oversight of the agency. The provider had developed an action plan which lacked detail”
criticalPerson-centred care: “one person was prevented from attending day care services or having treats due to being 'rude'”
criticalOther: “Recruitment procedures followed were not robust and did not ensure the staff employed were suitable to work with adults at risk.”
moderateLeadership: “She [provider] doesn't always come back. I have to ask her to respond. I try not to bother... She has left me to get on with it.”
moderateStaffing levels: “there was insufficient staff to cover annual leave and sickness... one member of staff was on duty for four weeks”
moderateSupervision / appraisal: “One to one supervision to discuss performance, personal development and training needs were not taking place regularly.”
moderateCare planning: “Care plans were duplicates of the daily routine plans... comments from staff indicated that care plans were not a true reflection of people's current needs.”
moderateRecord keeping: “Daily notes were not always signed or dated by staff... Daily notes were not audited robustly”
moderateIncident learning: “There was little evidence that there was learning opportunities for staff. Daily notes evidenced that incidents where people challenged the service were not reported.”
Strengths
· Adequate supplies of personal protective equipment (gloves and aprons) were available
· People were supported on healthcare appointments and to access NHS facilities such as dentists and opticians
· A relative praised staff: 'They are very good. They go the whole mile. They look after her to the best of her ability.'
· Staff knew people's life stories and preferences and developed bonds with people over time
· Provider had identified staff training needed to improve and contacted training agencies for online packages
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Using medicines safelyInadequate
safe: Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement