CQC Improvement and Action Plan

CQC Improvement and Action Plan

Service Name and Location:Victoria Court

Registered Manager:Miss Lyn Young

Date:25th September 2015

Date of review:25th October 2015

Progress Key
Delivered and Complete
Some issues outstanding
Not delivered and needs action

This document outlines any improvements and actions required following a CQC inspection. It sets out what improvements we need to make, what actions we are taking to meet the necessary standards, a timeframe for this plan, and the progress of the plan. A key will be used to highlight whether the proposed improvements and actions have been delivered, whether some issues are still outstanding, and when they have not been delivered.

Date of inspection report: 9th September 2015

Rating for the Service was:

Safe:Requires Improvement

Effective:Good

Caring:Good

Responsive:Good

Well Led:Requires Improvement

Overall Rating of this service was as follows: Requires Improvement

Key for Persons Responsible:

RM = Registered Manager

OM= Operations Manager

HSO= Health and Safety Officer

QCC= Quality and Compliance Consultant

KW= Key Worker

NI= Nominated Individual

SL= Shift Leaders

HR= Human Resources Department

Action Plan

CQC Action Requirements and Recommendations / CQC Regulation and Key Question / CTS Improvement and Action Plan (and Evidence) / By Whom / By When / Progress / Signed off
We found that the registered provider was not protecting people from the risk of infections. Staff did not always use personal protective equipment appropriately and the laundry arrangements were not in line with the Department of Health’s infection prevention and control and related guidance. / Regulation15HSCA(RA) Regulations 2014 Premises and equipment
Regulation 15(2)
SAFE and WELL LED? / Infection Control Refresher training to be given to all staff at VC. (Training Matrix and list of staff who have completed training kept in cqc file).
Infection control audit to be carried out immediately by manager with recommendations and action plan to be implemented. Findings to be submitted to Health and Safety Officer and Compliance Consultant (Audit forms and action plans). Audit to carry on monthly.
Health and Safety (including Infection control sub heading) to be added as ongoing agenda item for daily briefings/handovers, and shift leader meetings – (Agenda Template to reflect this). Any actions clearly documented with timeframes to complete these.
Daily handover sheets reviewed weekly by manager and Health and Safety Officer and audited monthly by manager. Any action plans to be put into action and signed off when complete. (Audit sheet and action plans).
Manager to have a weekly checklist proformaincluding health and safety –infection control (proforma).
Sit and See Tool used twice a week by manager to observe infection control in service. (Forms used for sit and see). Any issues arising to be addressed individually with staff member through supervision (documented in supervision notes)
Weekly checks of cleaning rota by shift leaders (forms for checks signed and dated) and monthly audit of these checks by manager kept on file (audit form). Any actions required to be addressed by manager with action plan (action plan).
Daily spot checks of laundry room by shift leaders(forms for checks signed and dated). Any actions required will be reported back to manager immediately to be actioned. Manager to carry out weekly audit to check for emerging themes including positive ones and these will be shared with staff group (audit form).
Daily log to include:

Aprons and gloves available
No baskets are stacked
Room is clean and tidy
Extractor fan is dust free
Lint filter in tumble dryer is dust free
An area to log concerns/actions taken.
Any other issues

/ Training department and signed off by RM
RM and checked by HSO, OM and QCC
RM
RM, HSO and OM
RM
RM, OM
SL, RM
SL, RM, OM
RM / End Sept 2015
To be started immediately then monthly ongoing.
End Sept 2015
End Sept 2015
Started 25th September 2015 and ongoing.
Manager starting sit and see 25th September 2015 and then ongoing twice weekly.
Weekly checks to start at end of September.
Monthly audit to start in Oct
Daily spot checks implemented from 18th September with weekly audit to start 25th September and ongoing weekly.
Immediately / Training in progress. Not yet completed. To be signed off when completed.
Audit has been completed 25th September.
This will be ongoing monthly. Recommendations to be submitted to Health and Safety Officer and Compliance Consultant.
Forms have been changed to include this agenda item. Action Planning Form in place.
Meetings ongoing.
Manager has started reviewing daily handover sheets. Audit to be started after one month.
Checklist has been started and will be ongoing.
Health and safety walkaround was completed 19th September.
Manager has started the sit and see assessments and these will be ongoing.
Weekly checks have been started by Shift leaders and will be ongoing. Monthly audit will occur in October
Daily spot checks started 18th Sept. Weekly audit started 25th September and ongoing.
Daily log created and started – this is ongoing
The registered provider had not ensured the protection of people from unsafe or suitable care through robust recruitment procedures being in place.
Not all new staff had received full DBS checks. / Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed
Regulation 19(1)(a)(2)
SAFE and WELL LED? / No new staff to be working in service without full enhanced and satisfactory DBS and two satisfactory references in place. Policy amended to reflect this clearly (Policy, posters, letters, audit).
If there are issues raised on DBS, risk assessment to be carried out before individual is allowed to work in any service. / HR, RMand CTS whole Company
HR, RM, OM / ASAP / CTS has now revised policy to make it very clear across all services. CTS have alerted all staff and updated their policies accordingly. A poster was sent to all services highlighting the change and this has been signed by all staff.
All new staff who are appointed are sent a letter which clearly indicates that new staff cannot start work until two satisfactory references and DBS check have been received.
This is now complete but our external compliance consultant is also auditing HR files to ensure compliance with the amended policy.
Risk assessment is now in place and will be carried out with HR/Manager and Operations Manager before anyone is allowed to start in services. Action Met / Dr David Bladon-Wing
September 24th 2015
We found that the registered provider had not protected people against the risk of duplicate and out of date records. Records we found to be out of date and inaccurate included people’s profile portraits, personal evacuation plans, risk assessments and fire plans. / Regulation 17 HSCA (RA) Regulations 2014 Good governance
Regulation 17(2)(c)
WELL LED? / All files for service users to be updated, old information archived and profiles and pictures renewed. (Files).
All files to be regularly reviewed and updated by keyworkers and audited monthly by manager with any action plans written down and fed back to staff team (clinical file audit forms and action planning form). File review and checks to include all file information, care plans, risk assessments to ensure there is no missing, out of date or duplicate information.
Files also to be checked by clinical team during monthly clinical meetings.
PEEPs all to be updated with review sheets attached and to be reviewed every 6 months or unless something changes (PEEP sheets and attached review sheets).
All risk assessments to be updated and reviewed monthly– or when something changes - using a review sheet. Audits to check risk assessments are being reviewed.
All fire plans to be updated and then regularly reviewed every 6 months. / RM. KW
RM, KW, OM
Clinical Team
RM, KW, HSO
RM, KW, OM
RM, HSO / All out of date information to be completed by end of September.
Reviews to start immediately.
Audit to start October 1st and then ongoing monthly
By end of September 2015
By End of September 2015
6 monthly reviews to be completed. / All files have been updated, old information archived and all files condensed into one file using new system across CTS. New photos with review dates now in place. Action met.
Reviews by staff have started. Audit to start 1st October and then ongoing monthly.
All PEEPs have been reviewed and duplicates archived – Action Met.
Reviews to occur every 6 months.
All risk assessments updated, old ones archived and review sheets in place. Action Met
Monthly reviews and audit to occur as ongoing
Fire plans have all been updated and old ones archived.
6 monthly reviews to occur.
There was no overall analysis of actions to be taken following comments received from annual surveys / WELL LED? / Audits to be completed on all satisfaction surveys annually and action and improvement plans submitted to SMT and put into practice. / RM, OM, NI / Annual audit summary and recommendation plan to be completed by end October and sent to SMT / All audit summaries completed and sent to SMT
Action met by end of September

As well as the above, which will be reviewed monthly by SMT, the registered manager will be writing to all the people who use the service including individuals, their families, and staff to inform them of the outcome to provide them with the one page summary of the inspection and to alert them to the action plan that is now in place.