Introduction to the Care Quality
​​​​​​​Commission Inspection

As the independent regulator of health and social care in England, it is the Care Quality Commissions (CQC) role to register, monitor, inspect and rate care services. They offer a transparent and independent view of these services and take action, when required, to protect those who need to use them.

It is the CQC's purpose to ensure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve.

Most importantly for us here at The Grove, is to take the opportunity to improve our service in order to meet and exceed the ever changing, long-term and complex needs of our nation's population. As a result of the findings of the most recent CQC inspection, held on the 14th & 15th November 2017, we have proudly instigated measures to strengthen our leadership and take action in a responsive and agile manner.

As the positive impact CQC has on the care industry continues to grow (as evident in their own review), we are committed to continuously improving our service and look forward to welcoming them back for the next inspection.

Summary of findings

All services are graded by the CQC on the same five areas:

• Is the service safe?
• Is the service effective?
• Is the service caring?
• Is the service responsive?
• Is the service well-led?

Areas requiring improvement
​​​​​​​and our action plan

The following is a summary of our action plan for areas that were marked as "Requires improvement". The CQC requires this action plan to be sent to them, following an inspection, for their review.

Is the service safe?

"Systems for the administration and storage of medicines were robust. However, the recording of the stock held of medicines that required stricter controls was not robust."

• A full audit of all medication will take place on a monthly basis.  All staff who are trained in medication will have a refresher course in Jan 2018 and will need to be signed off by the manager as competent.
• Stock levels would also be checked when new medication was booked in. Returns will be made on a weekly basis.
• Also, management  / a member of the senior team, will carry out an audit of all refrigerator drugs once a week, which will be recorded.
• Homely remedies are relatively new to The Grove. However, full procedures will be followed when dealing with them, including a monthly audit of all HR’s held.
  
  

Is the service responsive?

"The service was not entirely responsive. Care plans did not always contain accurate information for staff. Some care plan guidance was not being recorded by some staff."

• All Care Plans are to be fully audited by the management team.
• Training workshops will be held by the management team for each member of the care staff. Areas covered will be how to record accurate information in the “here & now.”
• All staff attending the workshop will have certification upon completion of training. Care Plans will be reviewed by management monthly to monitor the accuracy of information recorded.
• A member of the management team will be responsible for the setting up of new Care Plans.

"Monitoring records were not accurately and consistently completed by staff. These records were not checked for any gaps or inconsistencies."

• The Skin Bundles have been updated with immediate effect.  Workshops will commence in early January 2018 and will be certificated when complete.  Skin Bundles will also be part of the senior checks at the end of each shift, ensuring that they are completed accurately.
• Further staff training – 4 staff members, including a senior & also the manager, attended a skin pathways course to broaden knowledge & disseminate down through the care staff team.
• All food & fluid monitoring charts will be collated and analysed by the senior shift lead at the end of each shift, whereby any issues can be flagged up & responded too.  All F & F charts will be audited on a monthly basis, along with weight charts.
• All kitchen staff will be made aware of service users who are on a food & fluid chart. They will receive training in completing these records, by the management team, so as to achieve consistent results.

Is the service well-led?

"The service was not entirely well-led. Concerns found at this inspection had not always been identified by regular checks and audits. For example, medicine recording errors, incorrect pressure mattress settings and emergency evacuation information for people living at the service."

• Staff will be given a medication refresher every 4 months and this will be recorded on their training files.  Management will also carry out medication spot checks.
• Pressure mattress settings are now held within individuals Care Plans.  Any changes by visiting District Nurses (DN's), following changes in weight etc., will also be recorded.  If a mattress setting alters this will be reported by the senior on shift to the DN’s. The new senior handover, which will incorporate several other changes, will be in place from early Jan 2018 onwards. 
• A review of all residents Personal Emergency Evacuation Plans (PEEPs) is underway and will form part of the individual Care Plan. 
  ​​​​​​​

"Action was not always taken to address identified issues. For example, staffing pressures in the afternoon/early evening, and visiting healthcare professionals concerns about record keeping."

• The rota has been thoroughly reviewed and there are now 6 care staff on shift between 17:00 – 19:00.  This reduces down to 4 at 19:00, reducing down to 3 at 22:00. These changes were put into effect immediately.
• This was addressed immediately. Diagrams are placed within the middle care staff office and are also on the reverse of the new Skin Bundles.
• Training will also be wrapped up in the workshops provided for all care staff, as above.

Continuous improvement and
​​​​​​​striving for excellence

Working in collaboration with the CQC, as well as boosting our clinical and business support networks, has given us a much greater scope for creating an improved quality of service for our users. Adopting a culture of continuous improvement ensures that we can maintain a high level of care, as expected of us by our governing bodies, and demonstrates our desire to strive for excellence in everything we do.