Walsingham Support – Home Counties Outreach Services was rated Requires Improvement overall following an August 2023 inspection, with breaches of Regulations 12, 17 and 18 identified relating to unsafe risk assessments, unreported incidents, incomplete staff training and poor governance. The service had operated without a registered manager for a period, undermining oversight, though a new registered manager was aware of the issues and had begun remedial action.
Concerns (9)
criticalCare planning: “The provider had not ensured people's risk assessments were up to date. We found lengthy periods where some had not been reviewed.”
critical
Incident learning
: “Staff did not always record incidents. We found examples of incidents which had not been reported.”
criticalStaff training: “The provider had not ensured staff were up to date with mandatory training or ensured competency assessments were completed.”
criticalGovernance: “The provider had not ensured service managers were supported during a lengthy period when there was no registered manager.”
moderateSupervision / appraisal: “Supervision was meant to be held every 6 to 8 weeks; this differed across the 4 services and not everyone had received an appraisal.”
moderateConsent / capacity: “Staff had not ensured MCAs were completed and best interest meetings held for all decisions.”
moderateStaff competency: “Staff did not always support people as described in their risk assessments. We observed staff give a person food which had not been prepared in line with their SALT assessment.”
moderateRecord keeping: “Some actions were overdue and some had been marked as complete where we found the issues remained during our inspection.”
minorPerson-centred care: “Staff did not always encourage people to do what they could for themselves. They prepared food and did laundry without involving people to promote their independence.”
Strengths
· Staff understood how to protect people from abuse and could describe types of abuse and reporting procedures.
· The service had enough staff, including 1-1 support for people to take part in activities.
· Medicines were administered safely with correctly completed MAR records.
· Infection prevention and control measures were effective and the service was kept clean.
· Management were visible, approachable and known to lead by example with hands-on shifts.
Quality-Statement breakdown (14)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
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 staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement