Emmaculate Care Services Northampton Office was rated Good overall at this first inspection, with Safe rated Requires Improvement due to inconsistent PRN medicines records and incident recording that needed embedding. Effective, Caring, Responsive and Well-led were all rated Good, with consistent, well-trained staff, person-centred care plans and strong management oversight.
Concerns (8)
moderate
Medication management
: “medicine administration records (MAR) were not always clear regarding when the medicine was administered, who administered the medicine, the single dose given and the reason”
moderateMedication management: “This put people at risk of overdosing and not receiving their medicines as prescribed.”
moderateIncident learning: “Recording of incidents required embedding into practice. Incidents of behaviours that put people at risk of harm required more detailed recording.”
moderateRecord keeping: “records of behaviours were not always recorded on the correct forms. This meant information was not always consistently recorded with all the details required.”
moderateGovernance: “the audits on medicines had not identified the concerns found on inspection.”
minorCare planning: “positive behaviour plans required additional information regarding any restrictive practices required.”
minorStaff training: “Information recorded regarding staff training was not up to date during the inspection. The information showed some staff had not completed the training specified by the provider.”
minorCare planning: “Care plans held some minor conflicting information within them. The registered manager agreed to amend these documents immediately.”
Strengths
· Consistent staff team who knew people well, were sufficiently trained and safely recruited
· Risk assessments completed with mitigating strategies recorded; proactive approach to managing risks
· Safeguarding training and processes in place; people and relatives reported feeling safe
· Embedded infection prevention and control with appropriate PPE use and COVID-19 testing
· Person-centred care plans including likes, dislikes, routines, culture and religion
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
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 abuseGood
safe: Staffing and recruitmentGood
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: Staff working with other agencies; supporting people to live healthier lives and eat/drink enoughGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships and follow interests/activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive, person-centred culture; clarity of roles, performance, risks and regulatory requirementsGood
well-led: Engaging and involving people, the public and staffGood
well-led: Duty of candourGood
well-led: Continuous learning and improving care; working in partnership with othersGood