M N Pulse Solutions

Social Care Org · West Midlands

Overall Rating
Requires Improvement Last inspected 30 August 2022
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

8 must-do actions
5 should-do actions

Must-Do Actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
Improvements were needed to ensure staff were consistently recruited in a safe way.
We reviewed two staff employment records and whilst both had a DBS (Disclosure and Barring Services) and identity checks had been completed, we found gaps in other important information. One staff file had gaps in employment and education history, and these gaps had not been explored by the registered manager …
Must Do
Safe
Improvements were needed in obtaining references.
References had not been sought for one staff member from their most recent employer or place of education.
Must Do
Safe
improvement was needed to include information about their medicines within their care plan.
Staff did not currently have information available to them about a person's medication to refer to in the event of an emergency.
Must Do
Safe
improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.
Whilst actions had been taken to minimise reoccurrence, improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.
Must Do
Effective
Improvement was needed to include mental capacity assessment information in people's care plans.
Care records detailed when a person could make day to day decisions about their care and support. However, more detailed information was needed where a person's capacity may vary and posed a potential risk to themselves or others through their actions.
Must Do
Well-led
Some improvement was needed to the quality checks that were in place.
For example, checks on staff employment records had not identified the short falls we found in robust staff recruitment.
Must Do
Well-led
Care plan audits had not always identified areas for improvement.
For example, one care plan reviewed had contradictory information which in one section stated a person was at low risk of dehydration and in another section recorded they were at moderate risk of dehydration because they may not be able to access drinks for themselves. Staff always left a drink …
Must Do
Well-led
Some improvement was needed to the registered manager's spot checks on staff.
Whilst spot checks had taken place, these had not always assessed staff's skills and competencies to ensure learning had taken place from the training given.

Should-Do Actions (5)

Recommended improvements to enhance service quality.

Should Do
Safe
The registered manager told us they would ensure staff training met the needs of the role.
Should Do
Safe
The registered manager assured us they would add detail to risk management plans.
Should Do
Effective
Improvement was needed to ensure staff consistently had the skills and knowledge they needed.
Should Do
Effective
Some improvement was needed in staff's communication with people and their relatives to ensure messages and information was clearly communicated.
Should Do
Effective
The registered manager agreed this may be too much information to retain in one session and to spread this over time and to increase their knowledge and competency checks on staff.
Location Details
CQC ID: 1-10161000025
Local Authority: Worcestershire
Region: West Midlands
Inspection Report
Type: Performance review and assessment
Date: 30 August 2022
Rating: Requires Improvement
Actions: 8 must-do , 5 should-do
AI-extracted 17 Feb 2026