First inspection of a small domiciliary care agency rated Good across all five key questions, with people benefitting from consistent, culturally-aware staff and positive leadership. Minor improvements were recommended around medicines audit, COVID-19 testing compliance, capacity assessments, incident learning and higher-level governance audits.
Concerns (7)
moderate
Infection control
: “Staff had not been testing for COVID-19 in line with national requirements, as the provider had not fully understood current guidance.”
moderateGovernance: “Certain areas of audit were not yet fully developed to ensure quality performance in future... lack of higher level audits”
minorMedication management: “There were not fully developed systems for auditing medicines support... there were not formal systems for auditing medicines which would help the registered manager to identify areas for development”
minorIncident learning: “incident reporting procedures were not clear about the longer term action to prevent similar incidents from reoccurring.”
minorConsent / capacity: “the capacity assessment did not always ask questions which were in line with best practice.”
minorCare planning: “there were suitable risk mitigation measures in place but these were not fully detailed in the person's care plan.”
minorCommunication with families: “There were other documents which could have been provided in people's first languages such as support plans.”
Strengths
· Consistent staff who knew people's needs and could communicate in the same language
· People treated with dignity and respect; positive feedback from people using the service
· Safe recruitment practices including DBS, references and right to work checks
· Care workers completed the Care Certificate and received monthly training plus competency observations
· Detailed person-centred assessments capturing life stories, cultural and religious needs
Quality-Statement breakdown (20)
safe: Systems and processes to safeguard people from the risk from abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot 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 care; Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised careNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candour; Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated