Rapid Care

This was a focused assessment undertaken to follow up on the enforcement action we had taken.

We identified 2 continued breaches of the legal regulation in relation to safe care and treatment and good governance.

Although there had been an improvement in the assessment and management of risks identified at the last assessment, such as catheter care, we found 6 out of 7 people’s care records reviewed either did not fully assess or clearly plan for how to mitigate some people’s risks. There were multiple areas where key risk assessments or detailed guidance in people’s care plans were missing or incomplete, including for safe use of bedrails, choking risks, skin integrity risks and risks associated with people’s health conditions. The provider had made some improvement in how some medicines were managed such as clearer administration protocols for prescribed creams, but further improvements were needed.

The provider had not always taken sufficient timely action to drive improvement in all areas of the service. Governance arrangements remained inconsistent and had not been fully effective in identifying or addressing ongoing risks.

The provider had worked with external consultants and introduced new audits; some actions had led to improvements, while other areas needed further work to ensure robust and effective oversight. During the assessment, we found that new medicines audits failed to identify some of the issues we found at this assessment such as 2 people who did not have medicine administration records for their medicines.

Leaders were receptive to feedback and demonstrated a willingness to learn and improve. Action was taken promptly during the assessment to begin to address the issues found. The nominated individual also changed during the assessment, and they implemented further changes to strengthen governance and oversight at the service. These improvements were still new and not yet embedded.

However, feedback from people and relatives about the service continued to be positive. People told us they felt safe, and staff knew how to safeguard people. There were systems and processes in place to support staff to work in partnership with other relevant professionals to meet people’s needs. Staff knew people well and spoke confidently about their roles and responsibilities.

We have asked the provider for an action plan in response to the concerns found at this assessment.