First inspection of a newly registered domiciliary care agency rated Good overall, with Requires Improvement in well-led due to quality oversight systems not being effectively implemented and patchy embedding of learning. Despite a recent COVID-19 outbreak that affected staffing consistency, people received safe, caring, person-centred care from a committed team.
Concerns (6)
moderate
Governance
: “systems to support the provider to have good oversight of the service had not been effectively implemented.”
moderateGovernance: “the provider was not using the systems effectively to track that actions and learning had taken place”
moderateIncident learning: “There was a commitment to learning from mistakes, however this was patchy... but other office staff did not recognise this. This demonstrated systems were not fully embedded.”
moderateStaffing levels: “During staffing shortages, staffing was not always consistent... during this period the quality of rotas and staffing had deteriorated”
moderateLeadership: “service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
minorRecord keeping: “some medicine risk assessments had not been updated following an incident and refresher training had not been recorded centrally.”
Strengths
· Personalised risk assessments and detailed care plans giving staff guidance on safe support
· Safe recruitment with DBS checks and enough staff to meet needs
· Effective infection prevention and control, including managing a COVID-19 outbreak
· Staff received training including the Care Certificate, MCA training and supervision
· Caring, compassionate culture with staff who knew people well
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and management; Using medicines safely; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersRequires improvement