First inspection of newly registered domiciliary care agency rated Requires Improvement overall, with a breach of Regulation 17 (Good Governance) due to ineffective quality monitoring systems, gaps in medication records, vague risk assessments and expired staff training. Care was rated Good for effective, caring and responsive, with relatives describing staff as kind and the management team as approachable.
Concerns (7)
critical
Governance
: “The providers system to monitor the quality of the service was not always effective. This was a breach of Regulation 17 (Good Governance)”
moderateCare planning: “the care plan was vague and stated, 'use as trained.' There was no detailed instructions on how staff should use the equipment safely.”
moderateMedication management: “We reviewed medication administration records (MAR's) and found some gaps in recording.”
moderateStaff training: “A recent training audit identified some staff training had expired three months ago... This training included moving and handling and medication training.”
moderateStaff competency: “Most of the staff are great but there are some that don't know how to care for [relative].”
moderateRecord keeping: “Another person's assessment identified a need to monitor food and fluid, however, there was nothing in the care plan to guide staff in how to carry out this task.”
minorLeadership: “the registered manager there was no registered manager had recently left, and the service was being managed by the service director.”
Strengths
· Staff knowledgeable about safeguarding and how to recognise and report abuse
· Safe recruitment practices including DBS checks and references
· Person-centred care plans including life history, social, religious and cultural needs
· Staff treated people with kindness, dignity and respect according to relatives
· Effective PPE provision and infection control aligned with COVID-19 guidance
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated