CQC Rating – Good
The Care Quality Commission carried out an inspection of the service at Heartfelt Care on the 29th April 2024.
Their findings found that clients were well treated and supported. Staff understood people’s needs and preferences well and clients received consistent care. Staff respected and promoted people’s privacy and dignity and supported them to be as independent as possible. Clients and relatives told us staff were kind and caring.
Clients and their relatives felt listened to and commented positively about the management of the service and told us that staff arrived for their visits on time or, if they were delayed for any reason, the service let them know.
Staff felt supported and received supervision.
However, there were areas CQC identified as requiring improvement and the key points from the action plan that has been put in place to address these is as follows.
They said
The written care plans needed further details on how people wish to be supported, what people can do for themselves, life history, likes and dislikes, communication needs in relation to the accessible information standard and details of end of life wishes.
Our actions
We have introduced new guidance to how care plans are to be written up and are in the process of updating all care plans to address the improvements identified.
End of life wishes form also added.
They said
That care plans and Medication administration records need further details on how people took their medicines and the level of staff support required.
That more evidence of audits of MAR charts is needed and further guidance for staff on ‘as required’ medicines (PRN’s).
That all MAR charts need to be typed and not hand-written.
Our actions
Evidence that MAR charts are audited every month and any actions required are followed up is now in place.
An ‘as required’ medication form is now in place at every client and comprehensive written guidance has been put in place on all client’s medication.
All MAR charts are now typed up, checked, and countersigned by a senior member of staff.
They said
There needs to be a formal record that staff are competent to administer medication.
Our actions
A medication competency assessment has been put in place that all staff must pass. Further assessments are being made via spot checks and staff observations.
They said
Even though staff knew people well and they were able to describe risks to people and the action they took to mitigate these, not all risks to people were thoroughly assessed and mitigated in sufficient written detail.
Our actions
Specific assessments for each client are being detailed with written guidance on how to mitigate these risks are being put in place.
They said
A more robust system to document and review accidents and incidents is needed.
Our actions
We have put in place new incident reporting forms and a new audit process to follow up any actions arising.
They said
There are some gaps in in training on some subjects and some refresher training is required.
Our actions
All staff are now up to date with all their essential training. Additional guidance and training on subjects such as dysphagia, oral health and diabetes are being put in place.
They said
A formal quality assurance system needs to be put in place to monitor quality and safety.
Our actions
This is being developed and put in place.