Fulcrum Care, an independent care consultancy company, conducted a two day announced mock inspection at Active Care Group Care in the Home’s Children’s and Young Peoples service to evaluate compliance with Care Quality Commission (CQC) regulations and guidelines, as well as assess the service’s adherence to the Health and Social Care Act 2014. The focus of the inspection was to identify areas of improvement and provide recommendations to ensure regulatory compliance.
Below are some of the highlights that were taken from the mock report.
Safe Care and Environment
Proactive Safety Culture: The service has a proactive safety culture, where lessons learned from incidents and complaints are shared openly. Systems such as lesson learnt meetings, staff supervision, newsletters disseminate best practices among staff. These steps demonstrate the services commitment to continuous improvement and learning.
Staff Empowerment: Employees expressed confidence in raising safety concerns with leadership, reflecting a supportive environment. Staff reported feeling valued and heard, with the registered manager readily accessible to discuss any issues. The introduction of the Datix system enables ease of reporting and staff report positively in its ease of use.
Staffing and Training
Staff Files and Supervision: The onboarding of new staff is undertaken by the central recruitment team from the provider. Staff are unable to work until all compliance requirements have been completed. Supervision of staff includes 1:1 contact, spot checks, clinical supervision in the home and team meetings. Staff we spoke to report the value of the care and clinical managers regular visits which offer reassurance and support in ensuring they are undertaking clinical skills as taught.
Staff Training: The service uses a blended approach for training of both theoretical online training and face to face clinical skills training. Staff spoke positively of this blended approach.
Inspectors spoke to family of the children who receive care and they said, “All my staff are kind and caring. I feel safe to leave my child with the staff, they have been well trained and have the rights skills.”
Infection Prevention and Control
Risk Management: The service has a robust process for risk assessment for each individual child and their environment, with mitigation being clearly recorded.
Audit: within the governance framework infection prevention and control is included for audit. There was evidence of appropriate mechanisms to record incidents of infections, hand hygiene audits in the home and monitoring of trends for service improvement.
Medicines Management
Medication Administration: All children have medication risk assessments in place. Staff were supported in administering medication with electronic medication records. There was a robust system for transcription of medication. Family we spoke to reflected on the introduction of electronic medication recording as a positive change and felt it was safe than paper charts. It enables regular monitoring by the care managers and effective support for staff if required.
Effective Care Delivery
Care plans: Care plans were completed for each child or young person and were regularly updated. The format of the plans is under review with the draft document seen being much more child friendly. Family we spoke to reflected on the effective support their child receives and the trust they have in their staff in safe care delivery. Staff reflected on effective care plan and risk assessments, that enable them to provide safe care. Safe systems are in place to ensure plans are updated regularly and information disseminated to staff.
Caring and Responsive Service
Kindness and Compassion: Family members we spoke to, talked of their care workers positively. They were very happy with the care and clinical managers and felt their regular communication demonstrated their effective care and support to the child or young person receiving care.
Staff delivering care were very happy and confident in their roles and enjoyed working with their young person.
Governance and Leadership
Management: There is a strong management team in place. The Managing Director has enabled change to be positively implemented across the service and all staff we spoke to understand the vision for the service and the values of the provider. The registered manager is supported in the role with robust frameworks and structure and was seen to be a respected manager. Staff and families spoke of the effective communication which has been transformational in the delivery of the service.
Governance Systems: The service has developed a comprehensive governance structure and framework to enable audit, analysis, trend monitoring and service improvement. This is led by a strong quality manager who is visible and available to support the registered manager and team in ensuring KPI’s are met. The manager is creative in disseminating data in an effective way to the team that enables delivery of positive change.
Compliance with Regulations
Overall Compliance: The service appears compliant in all domains. Communication and working with key professionals involved in client care is clearly demonstrated. The current systems in place support the service to have a view daily of care delivery, through electronic medication and recording of daily notes within the OneTouch system. Training appears robust and where required adaptable to clients’ bespoke needs. The service is supported by Registered practitioners to oversee clinical safety in the clients home and support the registered manager in ensuring care plans and risk assessments are fit for purpose. There is good supervision and oversight of care staff in the home through 1:1 supervision, appraisals, spot checks and team meetings.
Conclusion
The service is delivering effective care to the children and young people. Communication has been strongly recognised by both care staff and client’s families as being much improved and is always appropriate, consistent and regular.
This has contributed to strong and trusting working relationships with the care and clinical managers and the children and young people they support, their families and the care staff who support them. The service is using digital technologies appropriately to enhance the delivery of service and enable ongoing oversight and analysis that provides information for analysis and continuous service improvement.
