Quadrant Court

People told us they were very happy with the overall service provided. They had no concerns, told us staff turned up on time and that they felt safe when supported by staff. Despite this, we found the systems and processes in place to support staff to do their job safely were not robust. Risks to people were not adequately assessed. Care plans lacked detail about people’s needs and risk assessments were not in place to provide staff with information needed to mitigate the risks to people and keep them safe from harm. Opportunities to learn lessons were lost as the provider’sapproach to reducing unwanted incidents was reactive, not proactive. Care records lacked sufficient information and guidance on people’s health care needs and how to support them to manage these. People told us they were involved in the planning of their care, but there was a lack of evidence to demonstrate this. Staff had received training in how to recognise abuse, but heavily relied on the provider to recognise and respond to any concerns. Recruitment practices in place were not robust and staff supervision and competency checks were inconsistent. Staff felt well trained, but systems were not in place that would assure the provider of the effectiveness of that training. There was currently no system in place to monitor the punctuality and duration of people’s care calls. Staff rotas seen indicated that, on occasion, some staff were expected to be in 3 places at once. Accidents and incidents involving people were not consistently investigated or reported appropriately. The provider had failed to follow their own accident and incident policy which meant opportunities to learn from these events and reduce the risks to people were lost. Systems were not in place to ensure medicines were administered accurately and in accordance with prescribers’ instructions. Medication audits had not been completed that would have identified some of the concerns found during the assessment.

Systems were in place to gather information regarding people’s health and care needs prior them being supported by the service. However, people’s care plans did not always reflect the information gathered. Risk assessments and information regarding people’s health care needs had not been put in place which would identify potential risks to people’s health and wellbeing and provide staff with the necessary information to support people safely and effectively. People were supported to access a variety of healthcare services and, on the whole, spoke positively about the care and support they received from staff and had no concerns. Systems were not in place to monitor and mitigate the risks to people. Accidents and incidents were not recorded which meant opportunities to learn lessons from these events were lost. People confirmed staff obtained their consent prior to supporting them.

People reported that staff treated them with kindness and were respectful towards them. People, relatives and advocates spoke highly of the provider and their caring nature. Staff were aware of what was important in people’s lives, including supporting people to maintain relationships with people who were important to them. Staff felt supported in their role and were complimentary of the provider. They felt well trained and able to raise any concerns with the provider in the safe knowledge they would be listened to and action taken. However, staff rotas were unclear and demonstrated that staff had not be provided with travel time between some calls and, on occasion, were expected to be in 2 or 3 places at once.

People reported their care was person-centred and the majority of staff knew them well. However, people’s care records did not reflect important information they shared with us about their individual needs and risks, which placed people at risk of receiving inconsistent, ineffective or unsafe care. People’s care records lacked detail and failed to reflect their physical, mental, emotional and social needs. Staff had not been provided with information regarding the risks to people and how to mitigate those risks and care records lacked information regarding people’s healthcare needs. Information was made available to people in a format that was accessible to them. People, relatives and advocates all felt listened to and reported the provider responded to any concerns they may have promptly and effectively, but there were no records available to demonstrate this. People were supported to access care services to help them maintain good health. The service did not currently support people who required end of life care, but the provider was confident that arrangements could be made to support people if required.

We found the provider had failed to operate effective governance systems to enable them to assess, monitor and improve the quality of people’s care. Although the provider was in regular contact with people, relatives and advocates, their governance systems and processes did not support them in maintaining oversight of risks, performance and outcomes. People, relatives, advocates and staff were complimentary of the service and spoke highly of the provider. They told us how accessible they were and responsive to any concerns raised. The provider had failed to consistently follow their own policies and procedures which would provide them with effective oversight of the service. They reacted to situations but did not consistently act to prevent situations occurring and mitigate the risks to people. Care records lacked important information that would support staff to carry out their role effectively, possibly reducing the number of concerns raised. The provider lacked sufficient understanding of the regulatory requirements associated with their role. The provider took on board all the feedback given during the assessment.