“No recorded complaints since 2015. What? Seriously? Wait, say that again.....” - me, 2024

Learning from CQC inspection reports: How better training and management could have prevented failures

In the world of home care, staying compliant and ensuring high-quality care is crucial. This week, I'm breaking down another recent CQC inspection report for a home care provider rated as inadequate. The lessons learned from these reports can help you avoid similar pitfalls and improve your services.

You can watch the full video here or see the summary below:

Key Facts about the home care provider

Overall CQC Rating: Inadequate (now in special measures) – Rated Good in September 2019

Clients: 228 adults and children

Right Culture: Lacked support for maximum choice and control; staff did not always support clients in the least restrictive way; policies and systems failed to measure quality and safety.

Right Support: Risk of harm was not always considered; medicines were poorly managed, especially "as required" medications; adequate staffing was in place, but calls did not always occur at preferred times.

Right Care: Care plans and assessments were lacking; independence was not promoted; staff were unaware of how health conditions impacted clients' needs, wishes, and abilities.

Individual CQC Ratings

• Safe: Inadequate

• Effective: Requires Improvement

• Caring: Requires Improvement

• Responsive: Requires Improvement

• Well-Led: Inadequate

Noting down some of the reasons

Is the Service Safe? No.

Issues identified:

• Lessons not learned: Poor safeguarding systems and lack of feedback mechanisms. Safeguarding concerns, including restraint, were not robustly identified, reported, or acted on.  Appears that no lessons learnt practices in place.

• Medication management: Instances of missed medications, incorrect doses, and inadequate information on medication contained within care plans. Risk assessments for medications like anticoagulants were missing.

• Infection control: Poor hand hygiene protocols were noted.

• Staffing: Safe recruitment practices were not always followed (for example original documentation not seen, missing references).  High turnover led to reliance on inadequately trained agency staff. Care calls were often short, late or rushed.

• Incident management: Incidents were not consistently recorded or acted on.

• Risk assessment: Risks were not adequately assessed or mitigated. Staff lacked knowledge on actions to take on, for example, client falls.

Actions to improve the service:

• Implement strict medication management protocols and re-training and competence assessments.

• Strengthen safeguarding protocols and train staff to identify and act on concerns.

• Enhance infection control training and monitoring.

• Recruit and retain permanent staff to reduce reliance on agency workers.

• Introduce incident and quality assurance management practices.

• Provide training in assessing risk and care planning to those carrying out, together with audits to ensure accuracy and robustness of those care plans and risk assessments.

Is the Service effective? No, it requires improvement.

Issues identified:

• Training and competency: Staff lacked essential skills and knowledge, including moving and handling. Competency checks were not carried out.

• Care planning: Again, care plans were outdated or lacked crucial information.

• Mental Capacity Act (MCA): Poor understanding and application of the MCA by manager, as well as care staff teams. Consent was not consistently sought, and capacity assessments were not decision-specific.

• Nutrition and hydration: Nutritional needs were not consistently met, and records of food and fluid intake were incomplete.

Actions to improve:

• Develop a comprehensive, ongoing training program with competency assessments.

• Regularly review and update care plans.

• Provide robust training for registered managers on the MCA.

• Implement systems to monitor and record nutrition and hydration.

Is the Service Caring? It requires improvement.

Issues identified:

• Late and missing Calls: Service users felt calls were rushed, impacting care quality.

• Compassion and respect: Some staff interactions lacked compassion and respect. Cultural sensitivity was not upheld.

• Dignity and privacy: Personal care was sometimes provided in communal areas.  Say what?

• Service user feedback: Lack of mechanisms for obtaining and acting on feedback from service users and their families.  It does not state it in the report but likely staff teams too!

Actions to improve:

• Conduct empathy and cultural awareness training.

• Ensure all personal care is provided in private settings.

• Establish regular feedback channels and address concerns promptly.

Is the service responsive? No, it requires improvement.

Issues identified:

• Care tailoring: Care was not tailored to individual needs, with many care plans being generic.

• Complaints handling: Complaints were not effectively handled, with no recorded complaints since 2015.

• Accessible Information Standards: Communication needs were not understood, and there was a lack of meaningful activities, leading to service user frustration.

Actions to improve:

• Personalise care plans to reflect individual needs and preferences, including accessible information needs.

• Improve the complaints process for timely and effective resolution.

• Introduce meaningful activities to engage service users.

Is the Service Well-Led? No, it really isnt.

Issues Identified:

• Leadership and governance: Weak leadership and poor governance. Managers were not visible or approachable, and there was no culture of learning and improvement.

• Quality assurance: Ineffective processes. Issues were not identified or addressed promptly.

• Staff morale and culture: Low staff morale due to poor management and lack of support. Person-centred care was not considered, and specialised training needs were unmet.

• Partnership working: Failings in partnership working, and duty of candour was not displayed during inspections.

Actions to improve:

• Strengthen leadership and make managers more visible and approachable.

• Implement effective quality assurance systems for regular monitoring and improvement.

• Improve staff support and development to boost morale.

Enforcement Actions Taken:

• Regulation 12: Safe care and treatment

• Regulation 13: Safeguarding

• Regulation 17: Good governance

• Regulation 18: Staffing

Lessons learnt that other home care providers could learn:  A summary 

• Improve medication management: Regular audits and staff training are crucial.

• Enhance infection control: Proper hygiene practices and regular monitoring.

• Ensure adequate staffing: Focus on recruitment and retention and if you get agency workers, test their competence and training records.

• Develop comprehensive training programmes: For all levels of staff.  (Need help? Get in touch!)

• Personalise care plans and adequate risk assessment: Tailor care to individual needs and know how to write up care plans properly and identify and reduce risks.

• Strengthen leadership and governance: Visible and approachable management.

• Implement robust auality assurance: Regular monitoring and improvement.

• Boost staff morale: Provide support and development opportunities.

These are just summary points for a recent CQC inspection report.

Need something a bit more robust?  Why not start with my training and development audit, using my new learning diagnostics tool, where you will get a much more in-depth report, together with real actionable insights.

Why not arrange a comprehensive training audit? Use our new learning diagnostics tool to identify and fix the problems within your service.

Ready to transform your training from MEH to Memorable? EMAIL ME - [email protected]

Stay tuned for the next post where I’ll cover another CQC report breakdown. Have a specific report you'd like me to review? Let me know over socials or drop me a message!