Sure Healthcare (Leeds) received an overall rating of Requires Improvement at its first inspection, with breaches of Regulation 17 due to absent or incomplete quality audits and oversight of medication records and care plans. Despite governance shortfalls, people and relatives praised the caring, consistent and person-centred support provided by a committed staff team.
Concerns (5)
critical
Governance
: “There was an audit tool in place but regular quality checks had not been completed. This included reviews of people's care plans and audits of medication charts.”
moderateMedication management: “One person was prescribed medicine to be taken four times a day. Staff did not record the times of administration which meant we could not be assured there was a four-hour gap between doses.”
moderateCare planning: “Some people's risk assessments did not contain a lot of detail and had not been recently reviewed. One person had experienced a recent significant fall but their risk assessments had not been updated.”
minorIncident learning: “The provider had a system for monitoring and reporting accidents. This could be improved to ensure near miss events were also captured and used to learn lessons.”
minorRecord keeping: “The registered manager and staff told us about examples where they had contacted and worked closely with health professionals. This was not always clearly reflected in people's care notes.”
Strengths
· People and relatives spoke very highly of the care, describing staff as kind, respectful and unhurried.
· Recruitment was managed safely with a rolling programme in place.
· Staff received regular training, induction, supervision and competency assessments.
· Consistent staffing enabled warm, person-centred relationships with people using the service.
· The registered manager was approachable, supportive and responded promptly to inspection feedback with an immediate action plan.
Quality-Statement breakdown (19)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff support: induction, training, skills and experienceGood
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
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
well-led: Governance, quality assurance and oversight systemsRequires improvement
well-led: Engaging and involving people, staff and promoting a positive cultureGood