All inspections: Collingwood Services Ltd

Our overall rating for this location stayed the same following our previous inspection in October 2021, however we improved the rating of the safe key line of enquiry to good as a result of this inspection. Our rating for well-led has stayed the same.

We could not rate the other key lines of enquiry because the service had not completed any regulated activity in over 12 months before our inspection.

We found the following:

The service controlled infection risks well, they had enough staff to care for patients and keep them safe. The equipment and vehicles were visibly clean and staff recognised incidents and near misses. Medicines were safely recorded and stored.

The service provided care and treatment based on national guidance and evidence-based practice. Staff had the knowledge to provide patients with practical support and advice to lead healthier lives. Managers monitored the effectiveness of the service.

The service planned and provided care in a way that met the needs of local people and the communities it served. People could access the service when they needed it and would have received care in a timely way if this was needed.
Leaders in the service were visible to patients and staff. Staff felt respected, supported and valued.

However:

Not all staff were compliant with mandatory training.

The service did not take account of patients’ individual needs. Staff were not aware of the policy regarding use of translators for patients who did not speak English.

Managers did not effectively manage risks to the service. The service did not always follow their own recruitment policy when employing new staff. Staff did not meet regularly to build relationships and discuss performance. The service did not seek views of staff to improve service for patients. Staff did not receive yearly appraisals and career development discussions.

We carried out this focused follow-up inspection on 12 April 2022.

We did not inspect all key questions as defined within our methodology but focused on those areas highlighted in the warning notice as requiring significant improvement following our comprehensive inspection on 27 October 2021.

We do not change the ratings of the service as we focused on the areas previously identified in the Section 29 warning notice.

The inspection was announced with two working day’s notice to ensure the registered manager and the operations manager would be available.

During our focused inspection we reviewed all information to ensure the required actions against the Section 29 served against the provider in November 2021 had been completed. We found that:

Staff files now included evidence of mandatory training and regular refresher training, including adult safeguarding and child protection training. Ambulance cleaning records were now up to date with an improved system of ensuring that deep cleans were effective. Two members of staff were trained in mask fit testing and several members of staff had been successfully fitted with appropriate masks.
Management had developed a system to improve oversight of staff mandatory training and appraisals.

However:

Although medicines management had improved significantly with improved procedures for paramedic grab bags, staff did not always dispose of unused liquid medication and expired medication correctly.
Staff did not complete medicine fridge temperature checks in line with the provider’s policy.
Filtering face piece (FFP3) mask fit testing was not completed for all active staff.
Some appraisal documents were incomplete.
Not all staff were included in the registered manager’s training and appraisal oversight document.

We rated this service as requires improvement because:

Staff were not in date for training in key skills and safeguarding policies were not based on national guidance. The service did not control infection risk well. The maintenance of vehicles and equipment did not keep people safe. They did not have systems and processes to safely administer, record and store medicines. The service did not manage safety incidents well.
Managers did not monitor the effectiveness of the service and did not make sure staff were competent. Managers did not appraise staff’s work performance or hold supervision meetings with them to provide support and development.
The service did not take account of patients’ individual needs. The service had not received complaints in the two years prior to inspection. Therefore, we were unable to see evidence of learning shared.
Managers did not always manage the priorities and issues the service faced. They did not complete appraisals which supported staff with their training needs. However, training courses, such as First Response Emergency Care (FREC) levels 3 and 4 were available for staff to improve their skills. There were not always effective governance processes. They did not collect and use data to make decisions and improvements. Staff did not meet regularly to discuss issues and service performance. The service did not collaborate with staff to help improve services for patients.

However:

The service had enough staff to care for patients and keep them safe. The equipment and vehicles were visibly clean and staff recognised incidents and near misses.
The service provided care and treatment based on national guidance and evidence-based practice. Staff gave patients practical support and advice to lead healthier lives.
The service planned and provided care in a way that met the needs of local people and the communities it served. People could access the service when they needed it and received care in a timely way.
Leaders were visible in the service for patients and staff. Most staff felt respected, supported and valued.

Collingwood Services Ltd

All Inspections

18 May 2023, 7 and 9 June 2023

During a routine inspection

12 April 2022

During an inspection looking at part of the service

27 October 2021

During a routine inspection