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

ReadyCQC

Concerns (16)

criticalCare planning: “Risks were identified in people's care plans, but there was limited information about how to keep people safe...staff felt they were going in 'blind'.”
criticalMedication management: “Two forms did not include the person's full name and one form identified them as the wrong gender...safe and proper management of medicines had not taken place.”
criticalInfection control: “Most staff we spoke with had not received formal training in relation to donning and doffing personal protective equipment (PPE) since the beginning of the COVID-19 pandemic.”
criticalGovernance: “The provider had developed a new quality assurance framework...The framework was only partially completed at the time of our visit.”
criticalLeadership: “The registered manager was not visible to frontline staff...Some staff we spoke with had not heard of the registered manager.”
criticalStaff training: “Annual moving and handling training was either incomplete or had elapsed for 22 of the 27 reablement assistants who delivered care in people's homes.”
criticalConsent / capacity: “People's assessments and care plans did not clearly document the assessor's view of the person's mental capacity, where people were living with memory impairment or confusion.”
criticalIncident learning: “There was no evidence effective or embedded systems were in place to analyse themes and trends from accidents and incidents, concerns and complaints and safeguarding concerns.”
moderateSupervision / appraisal: “The process of yearly direct observations had lapsed, meaning some staff had not been observed by a supervisor since early 2019.”
moderatePerson-centred care: “We identified 11 care plans where the person receiving support was described as 'client' or 'SU'...assessments lacked a holistic picture of the person.”
moderateComplaints handling: “There was no central record of concerns raised and informally resolved by the service...the registered manager and provider did not have oversight of concerns.”
moderateRecord keeping: “People's care plans often contained blank spaces where information such as people's preferred name, ethnicity, language or religion would be recorded.”
moderateSafeguarding: “Some staff had not completed safeguarding adults refresher training in line with the provider's policy...templates to record safeguarding concerns were not in use.”
moderateCultural competency: “We identified 15 care plans where the person's religion had not been documented, and six care plans where the person's ethnicity was absent.”
moderateCommunication with families: “One person commented, 'I have no idea who the manager is or what they are called'...management of the service was not inclusive or easily accessible.”
minorEnd-of-life care: “The end of life policy did not highlight the importance of holistic support for people and families at end of life.”

Quality-Statement breakdown (24)

safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
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: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Engaging and involving people using the service, the public and staffInadequate
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Working in partnership with othersRequires improvement

Reablement & Independence Service

Inspection reports (1)