Date of assessment 10 May 2024 to 14 May 2024. The assessment was prompted by information we received about the provider's licence for sponsoring visas for international staff. We assessed 15 quality statements and found a good standard of care was being provided. Rings Homecare Greater Manchester, is a domiciliary care service, registered to provide personal care to people living in their own homes. At the time of this assessment 32 people received personal care. People and their relatives told us safe care was provided by staff who knew people well and staff wore personal protective equipment (PPE) as required. Staff were recruited safely; pre-employment checks were completed to ensure applicants were of suitable character to work with vulnerable people. People and relatives spoke positively about the timeliness of care visits and the continuity of care and carers. Medicines were managed safely. Staff received enough training, supervision and support to carry out their roles safely and effectively. The provider had an up to date safeguarding policy and the registered manager followed the local authority reporting guidance. Staff received training in safeguarding and knew how to report any concerns. The provider learned from incidents and followed the duty of candour when things had gone wrong. The provider worked closely with the local authority to support people; they told us the registered manager was open and transparent and was helping to drive improvements. Care plans had risk assessments which were specific to each person. People and relatives were involved in care planning and completed surveys about care quality. The providers' audits captured information about actions and improvements as well as accident, incident and safeguarding records. There was evidence within care files of care reviews being completed.
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Rings Homecare Service Ltd (Greater Manchester) received an overall rating of Requires Improvement following a focused inspection in March 2023, with continued breaches of Regulation 17 in both safe and well-led domains due to poor medicines record keeping and ineffective governance audits. People and relatives reported positive experiences of timely, safe care, but the provider's failure to sustain improvements across three consecutive inspections led to the issuance of a warning notice.
Concerns (4)
criticalMedication management: “one person's medicine record had not been clearly amended to show a change in the strength of tablets supplied. A second record showed duplicate entries for administration of the same medicine over two days.”
criticalRecord keeping: “Record keeping relating to medicines management was not robust... breach of regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
criticalGovernance: “Regular medicines audits were completed but these had not been effective in identifying the issues found on our inspection. We have identified issues with aspects of medicines management at the last 3 inspections.”
moderateOther: “The provider agreed at the last two inspections to ensure de-registration forms were submitted for a previous manager... At the time of this inspection, these forms had still not been submitted.”
Strengths
· Care visits completed at agreed times with staff remaining for the full length of the call and no missed calls reported.
· Staff recruited safely with all pre-employment checks including DBS completed.
· Staff trained in safeguarding annually, with a recent practical refresher session held during a staff meeting.
· Care files contained a range of risk assessments covering health and safety, falls, manual handling, and medicines.
· Infection control policies up to date, with regular spot checks, audits, and an infection control champion in place.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
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: Engaging and involving people, the public and staff; Promoting a positive person-centred cultureGood
well-led: How the provider understands and acts on the duty of candourGood
Focused inspection found the provider remained in breach of regulations relating to safe care and treatment (medicines), person-centred care (visit timings) and good governance, with the new audit process not yet embedded. Overall rating remained Requires Improvement, with safeguarding, recruitment and infection control identified as areas of strength.
Concerns (9)
criticalMissed or late visits: “Timekeeping used to be okay, but not now, can be 40 minutes to an hour late. Last time this was discussed with the office, carers still arrived late the next day.”
criticalPerson-centred care: “The completion of people's care visits was not always in line with the agreed times as stated on their assessment and care plan. This is a breach of regulation 9 (Person centred care)”
criticalMedication management: “medicines were not being managed safely. Record keeping was inconsistent, including completion of MAR and records of people's prescribed medicines, and some people's medicines had not been given timely”
criticalRecord keeping: “Medicines Administration Records (MAR) were not always clear or completed fully. Missing signatures meant it was not clear whether people had received their medicines.”
criticalGovernance: “Systems and processes to monitor the safety and quality of service provision, identify issues and ensure actions and regulatory requirements were addressed timely, were not robust or fully embedded.”
moderateLeadership: “the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
moderateCare planning: “these did not always clearly explain what the risks were, how they impacted on the person's safety and what control measures were in place to minimise each risk.”
moderateCommunication with families: “One relative was unhappy the care plan had recently been updated without either them or their family member being consulted or informed.”
moderateCultural competency: “some people and relatives we spoke with raised concerns about some carers not speaking or having limited English and the impact this had on effective communication during care visits.”
Strengths
· Staff were recruited safely with all necessary pre-employment checks including DBS and references completed
· People told us they felt safe using the service and being supported by its staff
· Staff had received training in safeguarding and knew how to identify and report concerns
· Improvements made on infection control with up to date policies, PPE usage and adherence to COVID-19 guidance
· Registered manager was aware of their responsibility regarding duty of candour
Quality-Statement breakdown (9)
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
Focused inspection of this domiciliary care agency found breaches of Regulations 12 and 17 relating to medication safety, infection control, late/missed visits, inaccurate call monitoring and inadequate governance. Overall rating dropped from Good to Requires Improvement, with both Safe and Well-led rated Requires Improvement.
Concerns (11)
criticalMissed or late visits: “missed visits/near misses log held by the service which showed 11 had occurred in 2021, some of which had impacted on people's care”
criticalMedication management: “on some occasions staff had arrived within three hours to administer the medication again”
criticalMedication management: “Some people's MAR had unexplained gaps, making it difficult to establish if people had received their medication as prescribed.”
criticalInfection control: “Odd staff are still not coming masked-up and we are sure some are using the same PPE for personal care and feeding.”
criticalCare planning: “their care plan did not contain any information for staff to follow about this and a choking risk assessment had not been completed.”
criticalGovernance: “Quality monitoring systems were not robust. This placed people at the risk of harm. This was a breach of regulation 17 (Good Governance)”
criticalSafeguarding: “We had not been notified about a safeguarding allegation of financial abuse that had occurred.”
criticalStaff competency: “they did not always cover staff to work with children”
moderateStaff training: “We saw staff had not completed restraint training and recommend this is undertaken.”
moderateRecord keeping: “system did not show what time staff had arrived and left and in others, staff had failed to log in and out at all”
moderateLeadership: “the service had changed offices, but had not registered the new location with CQC before moving.”
Strengths
· Staff understood safeguarding and whistleblowing, with training completed for both adults and children
· Accidents and incidents were recorded, with actions taken to prevent future re-occurrence
· Satisfaction surveys, telephone reviews, spot checks and competency assessments were in place
· Staff meetings and three-monthly face-to-face supervisions were held
· Staff confirmed regular COVID-19 testing and both vaccinations completed
Quality-Statement breakdown (6)
safe: Staffing and recruitment; Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safely; Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
well-led: Continuous learning and improving care; Engaging and involving people using the service, the public and staffRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Working in partnership with othersRequires improvement