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

Inspection report · 2021-10-30

Framework: KLOE · 13 pages · 85 KB · PDF

Requires improvement

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

Langley House Care Centre was rated Requires Improvement overall following a focused inspection in March 2021, with breaches of Regulations 11, 12 and 17 identified relating to consent and Mental Capacity Act compliance, risk assessment and care planning, and ineffective governance and quality monitoring. The recently changed provider responded immediately to concerns and was already implementing improvements to care plans, staffing, audits and policies at the time of inspection.

Concerns (9)

criticalCare planning: “Care plans and risk assessments did not always reflect people's current needs or provide appropriate guidance for staff.”
criticalConsent / capacity: “People's capacity and ability to consent to particular decisions was not always assessed or recorded... not all people had capacity to give informed consent.”
criticalConsent / capacity: “DoLS were not always in place when required and were not always renewed when they expired.”
criticalGovernance: “Quality assurance within the service was ineffective. The provider's internal audits had failed to identify the issues found during this inspection.”
criticalRecord keeping: “When best interests decisions were made on behalf of people who lacked capacity, these decisions were not documented.”
moderateIncident learning: “Accidents were reviewed for overall trends but it was not always clear whether lessons had been learned and whether actions had been implemented.”
moderateRecord keeping: “Repositioning was not recorded and so we could not be assured this was taking place.”
moderateGovernance: “A number of issues were identified following a health and safety audit. There was no evidence of recommendations, actions taken, and lessons learned being recorded.”
minorCommunication with families: “The provider did not always engage and involve people, relatives and staff in an effective way. There were limited opportunities for people, relatives and staff to provide meaningful feedback.”

Strengths

· People said they felt safe and well cared for; safeguarding systems and policies were effective and staff understood their responsibilities.
· Medicines were managed safely with clear administration recording, correct storage, and person-specific protocols for when-required medicines.
· Sufficient staffing levels were maintained, with recruitment checks carried out safely and new provider increasing staffing.
· Infection prevention and control measures were robust; all IPC assurance criteria were met during the inspection.
· Staff had appropriate training, regular supervisions and appraisals, and were knowledgeable about individual residents' needs.

Quality-Statement breakdown (15)

safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to live healthier lives and access healthcare servicesRequires improvement

Inspection reports (3)