Focused inspection of safe and well-led found sufficient improvements to lift the safe rating to Good and remove previous breaches of regulations 12 and 17. Well-led remained Requires Improvement due to ongoing inconsistencies in record-keeping, late care calls linked to staff recruitment challenges, and governance systems needing further development.
Concerns (6)
moderateGovernance: “some further development was needed to ensure their systems assisted them to identify inconsistencies in some people's records.”
moderateRecord keeping: “we identified there were some inconsistencies in the records of some people's moving and handling and medicines plans.”
moderate
Missed or late visits
: “due to staff pressures that the staff did not always carry out their care calls on time.”
moderateStaffing levels: “The deputy manager explained recruiting staff had been challenging and a barrier to expanding the service safely.”
minorMedication management: “the professional's authorisation or dosage and frequency of creams to be applied was not recorded to guide staff and to help minimise any contra-indications with other medicines.”
minorCare planning: “we identified some inconsistencies in the quality of information in one person's manual handing assessments to guide staff on how they should be supported when using a hoist.”
Strengths
· People and relatives reported feeling safe and treated with dignity and respect
· Safe recruitment practices including background and criminal checks
· Improved risk assessment and management systems
· Prescribed medicines safely managed and staff trained in administration
· Staff trained in safeguarding and infection control with access to PPE
Quality-Statement breakdown (11)
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
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated