Southvale Care, a Southampton domiciliary care agency, achieved an overall Good rating at its first inspection, with strong person-centred care, consistent staffing and positive feedback from people, relatives and commissioners. The Well-Led domain was rated Requires Improvement due to ineffective internal audits failing to identify gaps in medicines records, moving and handling documentation, and two instances of notifiable safeguarding events not being reported to CQC.
Concerns (4)
criticalGovernance: “we found two of the examples of unexplained bruising that had been recorded and reported to the local authority, but information had not been shared with CQC, where this was notifiable.”
moderateRecord keeping: “audits of people's care records failed to identify our findings where records relating to people's moving and handling risks were incomplete or there were inconsistencies in completion of the provider's assessment tools.”
moderateMedication management: “Medicines audits did not identify our findings in relation to PRN protocols, consistency in MAR recordings or records relating to the application of transdermal patches.”
moderateGovernance: “some aspects of the provider's governance systems required improvement to ensure processes in place were robust to identify and drive improvement.”
Strengths
· Consistently positive feedback from people and relatives that staff treated people with kindness, compassion, dignity and respect.
· Electronic monitoring system used to oversee staff attendance, care call duration, and task completion with automatic alerts.
· Registered manager was highly responsive to inspection findings, taking immediate corrective action throughout the inspection.
· Strong positive culture supporting staff wellbeing, including a buddy system and community orientation for internationally recruited staff.
· Clear safeguarding systems in place; staff trained to identify abuse and knew how to raise concerns.
Quality-Statement breakdown (24)
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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 to provide consistent, effective, timely careGood
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, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood