Sams Medicare, a small domiciliary care service in Colchester, received an overall rating of Requires Improvement at its first CQC inspection, with a breach of Regulation 17 (Good Governance) due to ineffective audits and gaps in staff recruitment and induction processes. Care delivery was rated Good, with people reporting kind, consistent and personalised support from a dedicated staff team.
Concerns (7)
critical
Governance
: “Audits were ineffective and not reviewed regularly. We found these to be mostly tick box audits, without associated action plans, timescales for completion or staff identified as responsible.”
moderateStaff training: “Staff had not started the Care Certificate...induction lacked detail and comprised of 1 day of training which does not evidence a robust induction was completed.”
moderateStaff competency: “We did not see any records of 'spot check visits'. The latter enables the registered manager to observe the member of staff as they go about their duties.”
moderateRecord keeping: “We saw gaps in recruitment files, such as an application form not containing full employment history and staff were employed before relevant references were obtained.”
minorSupervision / appraisal: “Staff had received supervision. However, we did not see any records of 'spot check visits'.”
minorMedication management: “medication competency assessments...were completed in theory without the registered manager observing staff supporting a person with medication.”
minorEnd-of-life care: “There was limited information in the support plans we reviewed relating to people's end of life wishes.”
Strengths
· People spoke positively about care: 'Staff always go above and beyond and are amazing. I have no complaints. They are extremely considerate and kind.'
· Sufficient staffing levels with a small consistent team who knew the person well.
· Safeguarding systems and processes were in place; staff understood responsibilities for reporting concerns.
· Comprehensive, personalised care assessments and regularly reviewed support plans.
· PPE was available and replenished as required; staff received infection control training.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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 controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Continuous learning and improving care; Working in partnership with othersGood