ReadyCQC, a weekly field guide to CQC home-care regulation

Inspection report · 2022-04-13

Framework: KLOE · 17 pages · 99 KB · PDF

Requires improvement

safe: Requires improvementeffective: Goodcaring: Goodresponsive: Goodwell-led: Requires improvement

First inspection of a domiciliary care agency rated Requires Improvement overall, with a breach of Regulation 17 (Good governance) due to ineffective quality assurance systems that failed to identify shortfalls in risk assessments, medicines management and care plan detail. Effective, caring and responsive domains were rated Good, with consistent staff teams, kind person-centred care and positive feedback from people and professionals.

Concerns (6)

criticalGovernance: “The providers quality assurance systems and processes did not always operate effectively. Audits had not identified the shortfalls found during the inspection”
moderateMedication management: “guidance for staff to administer as required (PRN) medicines was inconsistent. There was not always a PRN protocol in place”
moderateMedication management: “Body maps and guidance documents were in place but these had not always been completed. Where people were using prescribed creams, information on how much cream, where and how often to apply was not always in place”
moderateCare planning: “People's care plans were not always completed consistently. Some care plans were lacking in detail which may mean people did not receive their care and support in ways they preferred.”
moderateRecord keeping: “People had risk assessments, but these were not always completed consistently or in enough detail to guide staff effectively.”
moderateComplaints handling: “there was not a process to review and analyse the complaints to enable lessons to be learned.”

Strengths

· People felt safe with staff who had appropriate training and skills
· Safe recruitment practices were followed with appropriate checks
· Staff received an appropriate induction and were well supported through regular supervision and training
· People received personalised care from a small, consistent team of staff who knew them well
· Staff treated people with kindness, dignity and respect

Quality-Statement breakdown (22)

safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires 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: Supporting people to eat and drink enough to maintain a balanced diet

Sylviancare Bournemouth and Poole

Inspection reports (2)