Focused inspection of safe, effective and well-led following concerns about recruitment and staffing, with all three rated Good and the overall rating remaining Good. Minor issues with employment history gaps, paused competency checks and notification confusion were addressed promptly by the registered manager.
Concerns (4)
moderateRecord keeping — “We found gaps in the employment history of some members of staff and an explanation for these gaps had not been sought.”
moderateGovernance — “The providers systems and processes had failed to identify the gaps in staff employment records which were found during the inspection.”
moderateStaff competency — “Formal staff competency checks had not taken place during the pandemic.”
moderateSafeguarding — “there was some confusion on the part of the registered manager regarding the need to alert the Commission of these concerns.”
Strengths
· Consistent group of staff supporting people with calls on time
· Staff trained in recognising and reporting abuse
· Medicines administered safely with reductions in inappropriate use
· Effective infection prevention and control measures including PPE
· Person-centred, holistic and strengths-based care plans
Quality-Statement breakdown (17)
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated